It's easier to avoid using potentially confusing descriptors than to disabuse patients of solidified misunderstandings later. In addition to reinforcing that you've communicated the limitations of medical diagnosis to the patient, your documentation in this section should preclude absolutism and provide an impressive record of your comprehensive care. Avoid false certainties in diagnoses and reduce the burden of unmet expectations by accurately aligning patient hopes with likely outcomes, and document that you've done so. To patients, their families and jurors, unmet expectations are the emotional equivalent of broken promises. Disappointment provokes anger.
Anger precipitates malpractice claims.
Understand that while patients may desire and appreciate immediate and firm diagnoses for their ailments, a diagnosis cannot always be given with certainty. Physical examinations, laboratory evaluations and imaging studies are better at ruling diagnoses out than ruling them in. Because of this and the revealing effects of time on treatment response, view diagnoses as works in progress and document accordingly. Clearly explain to your patient that the assessment is an opinion, new findings may develop, different explanations may be found and additional treatments may be necessary. Document that you've talked about this.