Monday, April 7, 2014

Is the "Clinical Impression" the same thing as the "Nutrition Diagnosis"?

After hearing the discussions at the recent Nordic Meeting for Dietitians about their use of the clinical impressions in daily practice, this raises the question of whether clinical impressions are the same as Nutrition Diagnosis?  

I can honestly say that I don't remember specifically learning about “clinical impressions” or hearing that term when I became a dietitian.  We were learning Nutrition Assessment, e.g. the different types of data to gather,  criteria to use to analyze the data before we recommended nutrition care and how to document using the SOAP format.  But I don't remember specifically discussing "clinical impressions".   And we all KNEW that only physicians could make a medical diagnosis (e.g. use the International Classification of Diseases).

Marion Hammond, Naomi Trostler and I are currently working on an article that describes the historical development of the Hammond Models describing clinical dietetics practice in the 1970 to 1989 at Pennsylvania State University.  In the Hammond Models from 1977 through 1986, there it is--clear as day!!  Under the Nutrition Assessment step the last activity is described as the clinicians’ subjective "impressions".

Other medical professionals use "clinical impression" in a variety of ways:
  •  Psychology may use the term to mean the judgment of clinicians (and patients) on the outcome of a therapy.  
  •  Patrick Negilan in the Critical Care Medicine Tutorials discuss the clinical impressions as a "state of the patient" declaration... a useful way of assessing the problems presented to you prior to your assessment, the new problems that you discovered, and whether these are resolving or not. 
  •  One VA posting indicates that “Impression is used by most practitioner's when completing the chart and used to formulate the plan of care. A definitive diagnosis is made when the impression has been confirmed by other diagnostic tests to include, labs, X-rays, mri's, biopsy etc”.
  •  Chiropractors refer to the clinical impression similar to the discussion by the VA, as the “working diagnosis” that must be used if there is an absence of a confirmed diagnosis. 
  •  Other sources seem to indicate that the “clinical impression” is the same as a “working diagnosis”

So then what is a diagnosis? 

The IDNT Reference Manual 2013, indicates that Nutrition Diagnosis is the identification and labeling of the specific nutrition problem that food and nutrition professionals are responsible for treating independently. 

However prior to the Academy acknowledging and promoting the concept of Nutrition Diagnosing, Dr Mary Ann Kight had pioneered work on nutrition diagnosing in the 1970's.  Sandrick shared some of Dr Kight’s perspectives in a 2002 Journal article called "Is Nutrition Diagnosing a critical step in the nutrition care process".  Dr Kight referenced medical literature from the 1960’s as guiding her development of the concept of nutrition diagnoses.  King described the three components that had to be present in a diagnosis: 
  1.   Pre-existing series of categories or classes with defining criteria that allowed for ruling in and ruling our placement into a category(ies)/class(es)
  2. The entity or object to be diagnosed
  3. A judgment that the object meets the criteria to be placed into a specific category/class versus a different category/class.

We can also look to other healthcare professions like nursing and physical therapy for their description of diagnoses within their profession.

A nursing diagnosis is defined as “a clinical judgment about individual, family, or community experiences/responses to actual or potential health problems/life processes. A nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse has accountability.” (Herdman, 2012, p. 515). 

Physical Therapy
“Diagnosis in physical therapy is the result of a process of clinical reasoning that results in the identification of existing or potential impairments, activity limitations, participation restrictions, environmental influences or abilities/disabilities.  The purpose of the diagnosis is to guide physical therapists in determining the prognosis and most appropriate intervention/treatment strategies for patients/clients and in sharing information with them.”

Bottom line:  Both terms involve the clinical judgments based on an analysis of gathered data about a patient/client’s condition and lead toward the next steps in providing healthcare for the patient/client.  However clinical impressions don’t always carry the formality that is attributed to a “diagnosis”.   To be a diagnosis, you need to have a list of apriori defined conditions with signs and symptoms that are used to determine whether the patient/client meets the criteria for one or more “diagnosis(es)”. 

Links to more information:

Nutrition Care Process SNAPshots.  Available at: Accessed April 7, 2014.

Sandrick,K .  Is nutritional diagnosing a critical step in the nutrition care process?   2002 Mar;102(3):427-31. PMID 11902381

Negilan, P.  Critical Care Medicine Tutorials. Available at:  Accessed April 5, 2014.

NANDA.  What is Nursing Diagnosis - And Why Should I Care?  Available at: Accessed April 6, 2014.

World Confederation for Physical Therapy, Policy statement: Description of physical therapy, Available at:  Accessed April 5, 2014.
Clinical Guidelines for Chiropractic Practice in Canada,  Chapter 7 - Clinical Impression and Diagnosis.  Available at:  Accessed April 5, 2014.

Difference between a Diagnosis and/or Impression.  Available at:  Accessed April 5, 2014.

What is in an "impression diagnosis"?  Available at  Accessed April 4, 2014.

Definition of diagnosis:  Available at:  Accessed  on April 6, 2014.

Definition of Medical Diagnosis:  Available at: Accessed April 6, 2014.

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