The other night I faced a dilemma. There was a 17 year old female patient in with abdominal pain – which halfway sounded GYN and halfway sounded GI in origin. She had some non-so-common medical conditions as well. First she had precocious puberty when she was 5 and was on Lupron to push it off until she was 12. Then she had her first period two years later. This corresponded with the development of anorexia nervosa which caused her to lose weight, develop abnormal liver function, and required her to be in counselling and on psych meds. Now, 3 years later, the anorexia was under control and she was off all meds – although still seeing a therapist. She was normal weight but still had irregular periods. She was recently started on provera to induce a period.
Now, the hard part was that her mother specifically asked me NOT to put down in her medical record that she had anorexia. I asked her if she was officially diagnosed with it and had specific treatment for it to which she replied yes. I told her I really should since it is important but she was insistent that I do not.
I was halfway thinking her pain was related to her liver and or GI issues but also the amenorrhea and GYN history also came into play.
I elected not to write it down in the record but felt like it was wrong to do it. Why didn’t they just not tell me she had anorexia!!?!?!? Tomorrow I am going to find out what ultimately caused her symptoms – and to see if anorexia might have played a role.
Weird. When you struggle/d with mental illness, you make a lot of decisions about what exactly you should disclose and to whom. But why freak out over what goes in her chart?
I guess it is just the principle of someone asking that an official diagnosis that may be important to their care be omitted.
I was diagnosed with Rheumatoid Arthritis(via many tests that tested positive w/a Rheumatologist) when I was in my early 20′s but my PCP decided to put non-specific joint pain on my records so I wouldn’t be turned down for treatment(pre existing condition) when I had to switch health coverage(I was in college an inevitably was going to have different coverage)
Maybe that’s why? Although if she’s already been treated for it..?…
Yeah, sometimes those diagnoses put in the chart come back to haunt you later. Like asthma will preclude military service, and jack up life insurance policy premiums, as will the rheumatoid arthritis. I am careful about what I add to the chart when I am doing triage for those reasons.
I have an ethical problem with lying in the pt’s chart. Leaving important things out is just as bad as making something up.
I guess you could say “mother reports pt has anorexia, unsure if this is correct or not” or something like that but all that will do is make it harder to help get the pt better.
If you don’t write it in the chart, it makes it allllll go awayyyyyyyy.
I would say that if they told me..it goes in the chart. If they didn’t want it there they should NOT have told you!
I have an issue with what to tell people about me, because I DON’T KNOW what is relevent or not. I have Ehlers-Danlos syndrome, asthma, allergies… lots of them, including penicillin. With penicillin, I have taken it before with no ill effects, but when I went for allergy testing, I found out I am allergic to it. Do I tell that to people? Do I also tel them I’ve had it before, and didn’t have any rash, shortness of breath, or an acute case of deadness as a result?