You must provide a diagnosis for every claimed condition listed on the Request for Examination or explain why a diagnosis is not possible. Evaluate each diagnosis you document in your examination report to ensure:

1. The diagnosis is clinically accurate and concurs with ICD-10 or DSM-5 as applicable.
2. The diagnosis is precise and identifies the disease process for the noted signs and symptoms. There are no rule-outs or non-committals.
3. The diagnosis is validated by primary source documentation. This is especially important for neoplasms and other conditions associated with a pathology report or a requirement of specific testing.
4. The diagnosis is supported by the history, physical examination, diagnostic studies, and other medical evidence.
5. Any discrepancies or changes from diagnoses of record are explained.
6. You documented that the claimant was notified of any clinically significant change or new diagnosis requiring follow-up.

The DMA C&P Disability Examinations Procedure Manual (Chapter 4, section d.vii) explains what is required for you to state that a diagnosis cannot be determined. First, you must explain why a diagnosis cannot be determined. It must be clear that you considered all pertinent and available medical facts to which the claimant is entitled. In addition, you must precisely identify what facts cannot be determined if you are unable to determine the etiology of a condition without resorting to speculation. In fact, you must not use the term, "Cannot opine without resorting to mere speculation" unless you have reviewed the pertinent literature and determined that the issue could not be resolved by yourself or any other clinician.