Assessment & Diagnosis Standards
Your diagnosis drives treatment decisions, follow-up planning, continuity of care, and national reporting. A vague or uncoded diagnosis limits every downstream use of the data — from the next clinician to MOH surveillance dashboards. A good assessment should be specific enough for another clinician to continue care without guessing your clinical reasoning.
This page information supports: SNOMED-CT ICD-10 ISO 18308
This page focuses on clinical content quality in assessments. For how to select and save SNOMED CT codes, see Clinical Coding. For the step-by-step click path, see How to Add a Coded Diagnosis.
The Six Checks
Before saving any diagnosis or assessment, confirm these six items:
- Every diagnosis must be clinically meaningful, not only a symptom label
- Uncertainty must be stated clearly as working, provisional, or differential
- Assessment must include the reason for the diagnosis and the reason for the plan
- Active problems that affect today's care should be coded and kept current
Vague vs Specific
| ⛔ Avoid | ✅ Prefer | ❓ Why It Is Better |
|---|---|---|
| Diabetes | Type 2 diabetes mellitus, uncontrolled | Guides intensity of management and follow-up |
| URTI | Acute viral upper respiratory tract infection | Signals likely aetiology and reduces unnecessary antibiotics |
| Gastritis | Acute gastritis with epigastric pain | Captures symptom + diagnosis together |
| Back pain | Acute mechanical low back pain, no radiculopathy | Documents key negative that changes management |
| Hypertension | Essential hypertension, Stage 2 | Supports risk stratification and targets |
| Fever | Acute febrile illness, dengue warning signs absent | Captures working condition and risk assessment |
Diagnosis Qualifiers
Include qualifiers only when they add clinical value:
Working vs Final Diagnosis
Working (Provisional)
Use when diagnosis is not yet confirmed but you need to start management.
- Label explicitly as Working diagnosis or Provisional
- Put the most likely diagnosis first
- Add differentials you are actively considering
- State what will confirm or refute it (tests, response to treatment)
- Update once evidence changes
Working diagnosis: Acute appendicitis (RLQ pain, fever, leukocytosis)
Differential: Mesenteric adenitis, ovarian pathology
Plan: Surgical review + imaging. Will update diagnosis after results.
Final
Use when evidence is sufficient and uncertainty is resolved.
- Use a specific diagnostic term
- Ensure correct SNOMED-CT coding + mapping to ICD-10
- Reference key supportive results if relevant
- Keep previous working diagnoses updated so the record does not contain unresolved uncertainty
What Good Assessment Documentation Looks Like
Assessment is your synthesis. It answers: Why this diagnosis? Why this plan? What risks did you consider?
Recommended Structure
- Clinical impression: severity and trajectory (stable, improving, worsening)
- Reasoning: key positives and key negatives that support your conclusion
- Differential (when relevant): what else was considered and why less likely
- Problem list: prioritised active problems
- Risk & safety net: red flags present/absent, who to escalate to, when to return
Template Snippet
Chief complaint: SNOMED CT code (mandatory)
Presenting history:
Assessment:
- Clinical impression:
- Reasoning (supports / against):
- Differential:
- Problem list (priority):
Management Plan:
Risk + safety-net:
Example: Complete vs Inadequate
Same patient, same complaint — two very different notes. Read both and notice what the second one leaves the next clinician to guess.
Example 1: Acute Case
Chief complaint:
- Central chest pain × 2 hrs (SNOMED 29857009)
- Character of chest pain: pricking, radiating etc.
Assessment:
- Alert conscious pink, GCS 15/15
- Lungs clear, equal AE
- CVS DRNM
- ECG: ST elevation II, III, aVF, no reciprocal ST depression
Diagnosis/Clinical impression:
- Dx: Suspected ACS
- Intermediate-risk ACS — typical pressure-like pain, smoker, age >45
- Differential: GERD, musculoskeletal
Plan: Aspirin 300mg stat. Urgent refer ED for serial troponin & observation.
Pt c/o chest pain. Looks comfortable, vitals stable.
ECG done — no acute changes.
T. Paracetamol 1g PO given. Pain settled.
Discharged. Follow up if worse.
The second note doesn't say what was ruled out, what would trigger escalation, why pain looked benign, or what happens if it isn't. The next clinician inherits the uncertainty.
Example 2: Chronic Follow-Up
Chief complaint: Chronic disease monitoring
Clinical Impression:
- T2DM with nephropathy, poorly controlled — HbA1c 9.2% (↑ from 8.4%), eGFR 45, ACR 35
- Reasoning: Persistent hyperglycemia despite adherence to meds.
- Key negatives: No hypoglycemia episodes, no foot ulcers
- Problem: 1) T2DM with nephropathy, poorly controlled 2) Hypertension (BP 148/92)
Plan:
- DM: Increase MTF to 850mg TDS (eGFR 45, acceptable).
- BP: Start Amlodipine 5mg OD. Target less than 130/80.
- Refer: Dietitian for T2DM education. Fundoscopy due (last >12mo).
- Ix: Repeat HbA1c & renal profile in 3/12.
Safety net: Return immediately if vomiting, reduced urine, or confusion. Hypoglycemia symptoms & action explained.
DM follow up. BP high. Continue Metformin and Glipizide.
FU 3/12. Diet advice given.
Key Takeaways
Contributor
Dr Fuad Jaafar
Facilitator, CCMS • KK Bandar Maharani