NUMBER OF DIAGNOSES OR MANAGEMENT OPTIONS
The number of possible diagnoses and/or the number of management options that must be considered is based on the number and types of problems addressed during the encounter, the complexity of establishing a diagnosis and the management decisions that are made by the physician.
Generally, decision making with respect to a diagnosed problem is easier than that for an identified but undiagnosed problem. The number and type of diagnostic tests employed may be an indicator of the number of possible diagnoses. Problems which are improving or resolving are less complex than those which are worsening or failing to change as expected. The need to seek advice from others is another indicator of complexity of diagnostic or management problems.
• For a presenting problem with an established diagnosis the record should reflect whether the problem is: a) improved, well controlled,
resolving or resolved; or, b) inadequately controlled, worsening, or failing to change as expected.
• For a presenting problem without an established diagnosis, the assessment or clinical impression may be stated in the form of differential
diagnoses or as a "possible", "probable", or "rule out" (R/O) diagnosis.