A member asked:

I want er to amend medical record with wrong axis ii diagnosis -got letter from my own doc, but she wrote axis ii deferred. will er fix?

6 doctors weighed in across 5 answers

Difficult....: Since your physician deferred an axis ii diagnosis, would be difficult but may place a statement in your record that you dispute it.

Answered 3/17/2014

4.3k views

Thank

Hard to say.: Usually er doctors are not the primary treating physicians. The diagnoses made in ers are tentative depending on further workup. If you own doc wrote axis ii: deferred, it just means that she did not have enough information to make a more definitive dx. I would not worry about it unless you think, it will effect your tx later on. Your med hx is based primarily on the DX made by your primary dr.

Answered 6/10/2014

4.3k views

Thank
Dr. Heidi Fowler answered

Specializes in Psychiatry

A/W Dr Husar: The er physician is putting his/her impression for diagnosis (unless making an error with information supplied to him/her from records). The er physician is not required to change the axis ii diagnosis - even if your therapist wrote no axis i diagnosis.

Answered 3/17/2014

4.3k views

Thank

It's worth a try...: ...But more likely the er will append your letter (or that of your physician) to their charted remarks to show that you disagree with what has already been recorded.

Answered 6/30/2020

4.3k views

Thank

Medical records: The entity you want to correct the records needs to be contacted. If the record in question was entered by the er physician, you will need to file your request with the medical records department of that hospital. If the entry was made by your regular physician, you will need to contact his or her medical records department with your request.

Answered 3/17/2014

4.3k views

Thank

Related Questions