Now that the electronic medical record is on-line and patients share in the information doctor’s kept ‘secret’ in the past, there are a lot of people who wonder about the diagnosis and comments in their chart.
Although the ideal chart would be purely a documentation of all the facts related to a patients conditions, it is in fact a much more complicated issue.
The chart serves many masters, most of which are practical and relate to insurance issues, billing, and prescription and test ordering. After those considerations, the chart is meant as an accurate repository of the medical history and to allow a quick summary of considerations that related to background health issues in the day-to-day care of the patient.
I often have a patient ask me, “Why does it say I have this diagnosis or symptom when I don’t think it is accurate?’ Sometimes they are correct and the information is there in error, but most of the time the information in contained in the chart to allow for consideration of various possibilities based on history and previous symptoms. To jog the memory, or to keep in mind as past conditions relate to current health complaints.
Doctors are aware of the potential fictional nature of the medical record, despite contending that it is an objective list of the various health issues at hand. We try our best to include all pertinent and important current and past medical history, but sometimes, the truth is a bit more complicated.
Twain remarked about something said from by friend…..”If it’s not true…it should be.”