The clinical impression is a summary statement created by healthcare professionals after evaluating a patient. It is the clinician’s initial working hypothesis about the patient’s condition, based on all available data. This documented interpretation of the patient’s immediate health status serves as the foundation for deciding the next steps in care, such as ordering specific tests or initiating management strategies.
Defining the Clinical Impression
The clinical impression is a professional judgment representing a synthesis of two primary data types: subjective and objective information. Subjective data includes symptoms reported by the patient, such as pain or nausea, and their medical history. Objective data encompasses measurable findings from the physical examination, laboratory tests, and imaging results.
The process transforms a collection of individual signs and symptoms into a single, cohesive statement about the most likely cause of the patient’s problem. It is often referred to as a “working diagnosis” or a preliminary assessment, recorded at the end of the initial assessment note to guide the immediate plan of care.
Distinguishing Clinical Impression from Final Diagnosis
A primary difference between a clinical impression and a final diagnosis lies in their degree of certainty and permanence. The clinical impression is inherently provisional and dynamic, reflecting the clinician’s best judgment at a specific point in time.
The final diagnosis, however, is a definitive label for the disease, disorder, or condition. This label is typically confirmed after all necessary diagnostic procedures, such as specialized lab work or advanced imaging, have provided conclusive evidence. The clinical impression is a necessary step within the diagnostic process, leading to the ordering of tests that aim to either confirm the initial impression or rule out other possibilities.
Essential Components of the Impression
A well-constructed clinical impression is a concise statement that integrates the problem, the supporting evidence, and other conditions under consideration. It is found in the “Assessment” section of common medical documentation formats. It typically begins with the single most suspected condition causing the patient’s symptoms.
The statement includes a brief summary of the findings that support the suspected condition, drawing from the subjective and objective data collected. The impression also often includes a differential diagnosis, which lists other potential conditions that have similar features and must be excluded through further investigation.
Practical Examples of Clinical Impressions
In acute medical care, the clinical impression focuses on immediate or time-sensitive conditions. A concise example is: “Clinical Impression: Acute appendicitis, rule out diverticulitis, supported by right lower quadrant (RLQ) tenderness, rebound guarding, and leukocytosis of 18,000”. This statement names the primary concern, lists the alternative, and provides the evidence that justifies immediate surgical consultation.
Mental Health Setting
In a mental health setting, the impression often incorporates psychiatric symptoms, functional impairment, and psychosocial factors. A typical impression might be: “Diagnostic Impression: Major Depressive Disorder, single episode, severe, with concurrent Alcohol Use Disorder”. This is supported by symptoms like depressed mood, passive suicidal ideation, and poor concentration, which are synthesized into the final impression.
Physical Therapy and Rehabilitation
For physical therapy and rehabilitation, the impression centers on musculoskeletal or neurological function and guides the treatment plan. An example could be: “Clinical Impression: Acute lumbar paraspinal muscle strain, secondary to lifting injury, evidenced by pain increase with lumbar flexion and objective limited active range of motion (AROM) to 30 degrees”. This structure links the suspected injury mechanism to the specific functional limitations measured during the examination.