Medical Records Question

[Hoppy]

Clinic notes contain an area that lists active symptoms. When the psychiatrist writes a report there is a section that states the active symptoms. They include things like syndromes, back conditions and psych diagnoses. The psychiatrist report shows active symptoms and a couple paragraphs later axis one diagnoses.

The problem we are having is that for a period of a year the Axis I diagnosis made by the psychiatrist is different than the listing of active symptoms. The active symptoms list states "panic disorder with agoraphobia". The axis I diagnosis shows "panic disorder without agoraphobia".

The question is Does the primary care doctor maintain the active symptoms list?

To really confuse things there is a report from an anxiety clinic that states that psychometric testing supports a diagnosis of agoraphobia. The report also includes in the summary a diagnosis of panic disorder with agoraphobia. However, when the clinic wrote the Axis I diagnoses it says "panic disorder w/o agoraphobia". We believe the w/o was a mistake. What we are thinking is that the primary care doctor caught the mistake and listed the active symptoms from the test results and the psychiatrist has been replicating the w/o mistake when he write up his axis I line. Panic disorder with agoraphobia is often way more disabling than without agoraphobia.

Edited July 18, 2010 by Hoppy

[stillhere]

Not sure who has the access and the authority to change and or post in them but I would go to the patient advocate at your MC and discuss this problem with them.

I have noticed in getting my records after a PCP visit and even after a shrink visit that they seem to be a little off as far as showing the conditions list.

[Hoppy]

The section I discussed on my original post is actually called "active problems" not "active symptoms" I am trying to figure who is allowed to input this section on the report.

[carlie]

Hoppy,

In my VAMC Progress Notes, in the section for "active problems",

I have information there that was entered by the person that took my vitals, etc...

prior to seeing whatever provider.

Further down these issues are addressed by my provider.

Wish I had more to give you.