Patient, demi daniels, calls to ask you to change her diagnosis in her medical record from r/o (rule out) bladder infection to “bladder infection” because her insurance will not pay for a r/o diagnosis. in fact, she tested negative for an infection, but the physician placed her on antibiotics anyway. what do i do?

A clinical record or medical record is considered a legal document. It serves as the proof of care given to a patient in any healthcare facility. Details included in this record, most especially the diagnosis should be accurate. However, there are circumstances wherein modifications are deemed necessary. For instance, to correct factual errors on care given, when the patient objects to the doctor's diagnosis or in response to an investigation or complaint. In the case given above, the motivations for the patient wanting to change the diagnosis is basically insurance related or financial. The patient is objecting the diagnosis because she wants the insurance to pay for the treatment. However she does not object to the diagnosis because she thinks that she still feels that there was still something wrong with her. The issue on why she was placed on antibiotics and on what kind of antibiotics will determine if you should change her diagnosis or not.

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