Primary Diagnosis

The main health condition or disease for which a patient seeks medical attention, and often the focus of treatment or intervention.

 

ICD-10 (International Classification of Diseases, 10th Edition):

A globally used coding system that provides alphanumeric codes for classifying diseases, conditions, and health-related issues, aiding in standardized record-keeping and billing.

 

Chief Complaint:

The primary reason a patient presents to a healthcare provider, expressing the symptoms or concerns that led them to seek medical care.

 

Differential Diagnosis:

The systematic process of considering and ruling out various possible causes for a patient’s symptoms to arrive at the most likely diagnosis.

 

Symptomatology:

The collection of symptoms exhibited by a patient, providing valuable information for healthcare providers to identify and diagnose underlying conditions.

 

Diagnostic Workup:

The series of tests, examinations, and evaluations conducted by healthcare professionals to determine the cause of a patient’s symptoms and arrive at a diagnosis.

 

Empirical Treatment:

Providing treatment based on the most likely diagnosis when a definitive diagnosis is not immediately available, often to alleviate symptoms or prevent complications.

 

Primary Care Physician (PCP):

The healthcare provider who serves as the patient’s first point of contact for medical issues and coordinates their overall healthcare, including diagnosis and treatment.

 

Clinical Decision Support (CDS):

Computer-based tools and systems that assist healthcare professionals in making informed decisions about patient care, including diagnosis.

 

Referral:

The process of sending a patient to another healthcare provider or specialist for further evaluation or management of a specific health issue.

 

Evidence-Based Medicine (EBM):

The integration of clinical expertise, patient values, and the best available evidence in the decision-making process for patient care, including diagnosis.