A patient has requested a copy of her clinical chart to be released to a specialist treating a newly diagnosed condition.

A patient has requested a copy of her clinical chart to be released to a specialist treating a newly diagnosed condition.  The specialist is interested in learning about any previous diagnoses, medications, and allergies the patient has had documented in the past. Upon review of the patient’s record, she notices that the patient has a diagnosis of a poorly functioning thyroid, but there is no evidence of treatment or medications. In discussion with the patient, the patient indicates she was never diagnosed with a thyroid problem.

Instructions: State your interpretation in response to the following questions.  Provide support for your rationale based on lesson content.

• What are the possible reasons for this diagnosis appearing in the patient’s medical record?

• What could have happened in the patient registration process to cause a problem with the clinical record?

• What could have happened in the coding process to cause the problem?

• If you were the patient with a wrong diagnosis on your chart, how would that impact your future relationship with the health care provider?