The process of determining the diagnosis is axis to the effectiveness of patient care. Diagnosis can be defined as a process of analyzing and interpreting clinical data to make conclusions (decisions) about the status (condition) of a patient’s health. The results of these conclusions or results can be stated as follows:
- Certainty of normal status (patient is actually healthy)
- There are changes that go beyond or are out of normal status (unhealthy patients)
- The certainty that a patient has a type of disease and the characteristic features or effects of that disease
Diagnosis is a core factor in determining treatment needs. Clinical service providers from various professions give different concentrations (focus) on what is referred to as diagnosis. Medical or dental practitioners (doctors) focus on determining the type of disease as clearly as possible. The nursing profession places more emphasis on the effects of disease on the comfort and ability of patients to perform a variety of activities. Thus the symptoms, signs and care needs are taken into account as the patient’s health problems referred to as Nursing Diagnosis. Therapists, on the other hand, focus on the effects of the disease on the physical, sensory or mental ability as well as the level of ability to perform various functions. Other service providers focus on specific matters according to their respective fields.
Purpose Of Determination Of Diagnosis
Apart from the author of the book CURRENT Medical Diagnosis and Treatment 2021 according to other articles there stated that the process of formulating and determining the diagnosis is a very important step in the ‘Clinical Workflow’ which consists of the following process rules:
- Generate and collect data on patients and their illnesses
- Analyze and interpret data to formulate diagnosis as well as patient needs.
- Plan patient care
- Give treatment
- Monitor the circulation of the disease
- Assess the effectiveness of treatment
- Review the diagnosis and change the treatment plan (if necessary)
- Evaluate treatment outcomes
- Continue treatment and decide on further action
How To Formulate And Determine The Diagnosis
The clinical provider determines the diagnosis as a result of the conclusions made through the process of analyzing and interpreting data on the manifestations of the disease in the patient and comparing it with what is known about the disease. Therefore, the ability to formulate a diagnosis depends on the provider’s existing knowledge and what can be gleaned from reference materials.
To formulate the diagnosis, the clinical provider analyzes the data through the following step-by step instructions:
- Make sure the value of the data is whether it is useful, authentic and sufficient
- Arrange, combine, break down and present in the form of text, graphics or tables to be more organized
- Edit the information as a summary
Thereafter, the clinical provider interprets the available information through the following approaches:
- Try to match the manifestations found in the patient with the manifestations (symptoms, signs) of various diseases known to him
- Predict the cause of abnormal symptoms, signs and test results based on basic knowledge including anatomy, physiology, biochemistry, psychology and pathology
- Decide on a disease or problem that (possible or obvious) the patient is facing using one of the two methods below or both:
- Compare the pattern of manifestation found in the patient with the known facts about the disease and its effects (pattern recognition)
- Make a list of possibilities and select one at a time and try to prove or disprove based on the diagnostic criteria (hypothetico-deductive approach)
Obviously the ability to determine the diagnosis is highly dependent on the knowledge and experience of the clinical staff involved. To get an explanation, the staff needs to get facts and clues from various sources or ask for expert opinion.