Old diagnosis in medical records

JKL33 · Apr 8

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I asked my PCP doctor to remove a very old,and I think, false diagnosis of a psychological issue from my online record and she agreed.

You say this diagnosis is very old. Is your current PCP the one who diagnosed you with the condition?

If so, use the clinic's process for submitting a request to amend your medical record. You may want to start with the office manager or the compliance officer. Although providers do have some official responsibilities when requests like this come in, they are not often the primary ones in the office to direct the process of getting it accomplished, as their primary activity during the day is seeing patients and following up on their medical problems/labs/results.

If your current PCP is not the one who originated this diagnosis, your first step is to contact the correct entity about this (the one that gave you the diagnosis).

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She lied it appears.

That's quite an uncharitable assumption.

It appears that she tried to do something that she believed would adequately resolve the problem--she inactivated the diagnosis.

You may not know this, but it's far more likely that she simply isn't fully aware of the specifics of this process than it is that she tried to bamboozle you and "lie" to you by (only) inactivating the diagnosis in your current chart.

Secondly, this process may not work the way you wish it would. I have not personally been deep in the weeds on this issue before (so I may be incorrect) but from a review of HIPAA information pertaining to this issue online, I don't think information can just be wiped from your record based solely upon your disagreement the way that you wish it could be. You can submit a request for an amendment based on your disagreement and if your provider agrees to the amendment then it will be made [note that this doesn't mean that any and all traces of the information will be removed from your chart completely vanished]. If the provider disagrees then they need to inform you and you can submit a statement of disagreement with their decision that must be posted to your record.

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I also think that the medical assistants have access to records.

Yes. It isn't possible for them to do their jobs without access to the records.

JKL33 · Apr 8

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false diagnosis

Decided to comment on this as well.

Your verbiage would be appropriate for an intentional act of putting a wrong diagnosis on your chart. Maybe you didn't mean that, but calling something "false" in this context, rather than inaccurate or incorrect, implies that the person knew a different diagnosis was "true" and chose not to use it.

More commonly, patients mean one of the following: 1. their condition has evolved and/or has been further investigated and differentiated to arrive at a diagnosis different than the original working diagnosis 2. A different provider had a different opinion 3. Their symptoms have improved and they no longer believe the original diagnosis reflects their current situation 4. They simply don't like it that their symptoms reasonably led to the diagnosis that was originally made 5. There was an actual record-keeping error and the diagnosis was charted on the wrong chart

The response to the request for amendment will depend on the situation and whether the provider agrees with the patient's perspective.

For example, say a patient is diagnosed with hypertension which then becomes controlled with lifestyle interventions and medication so that the patient's blood pressure is no longer elevated. If they want that diagnosis off their chart for life insurance purposes they may say, "That's an old diagnosis, I haven't had high blood pressure in years, I want that removed from my chart." Well....but they do indeed have hypertension which is being adequately treated, which is the work that the provider is being paid to perform *and* (even more importantly), it is a very relevant factor in managing the patient's health and deciding lots of other things about their care (eg what medications they should/should not take, what future disease risk factors they have, etc). It is not appropriate to think that diagnosis should be removed, nor should it even be inactivated or resolved as it is a problem that is both relevant to their health and actively being treated.