Working diagnosis
Also called Provisional diagnosis, Impression
A working diagnosis is the explanation you act on until new information confirms or replaces it, usually the top of your differential.
Why it matters in a workup
Name it and say how confident you are. The next doctor then knows what you are treating as true and what would change your mind.
When you cannot name one, say so and say what you need to find out.
Example
Typical angina, suspected chronic coronary syndrome, pending cardiology assessment.
Put it into practice
- Name it at the top of the assessment
- State your confidence
- Say what result would change it
Frequently asked questions
Is a working diagnosis the final diagnosis?
No. It is the best current explanation and can change as results come in.
General guidance on clinical documentation, not advice about any individual patient and not legal advice.
Glossary
Look up related terms
- Differential diagnosisA differential diagnosis is a ranked list of the conditions that could explain a patient's problem, with the reasoning for each position.
- Clinical reasoningClinical reasoning is how a clinician gathers information, weighs it and reaches a diagnosis and plan, including the checks against common errors.