When There’s Inaccurate Information on Your Psych Medical Record

An unfortunate reality of having a mental illness is that it’s fairly likely that inaccurate information will make it into your medical record at some point along the way. That might take the form of a misdiagnosis, inaccurate descriptions of how you were presenting, or inaccurate accounts of things you said. You might only learn of these errors some time later when another mental health professional is reviewing your older records. So, when you learn of these kinds of errors, what can you do?

Having the inaccurate information removed entirely may not be an option. Health professionals aren’t supposed to go back and change old charting; if, for example, a professional dropped the ball with someone’s care, they can’t go back and try to cover it up. And if professional B discovers an error in professional A’s documentation, they can’t just make that inaccurate bit of info disappear.

The one time I was able to get some erroneous documentation changed was when I’d had a review panel to contest my committal under the Mental Health Act. There were several factual errors in the decision letter, and because the panel had been audio recorded, the panel chair was willing to make the appropriate connections.

There’s a misdiagnosis in my chart from my first hospitalization. I was diagnosed with borderline personality traits (a lesser degree than borderline personality disorder) because I was a difficult patient, and from the treatment team’s perspective, difficult=borderline (a common stigmatized belief among health professionals). Luckily, subsequent treatment providers were able to recognize that this was inaccurate.

The most recent instance of inaccurate info in my chart was at the beginning of my recent admission, when nursing notes from the psych ER described me as yelling, combative, and paranoid. This was despite me speaking so quietly that everyone has a hard time hearing me, and the supposed paranoia was just me repeating over and over that I was a voluntary patient and wanted to leave. The ER psychiatrist charted that he had a hard time hearing me, and I was speaking so slowly that I was even taking pauses mid-word.

I didn’t learn about this until a week and a half later. At that point, I was on an inpatient unit and had no access to the nursing staff who’d documented that. My doctor on the inpatient unit didn’t meet me until 3 days after the made-up charting from ER. While he realized that it was a very unlikely account of events, he wasn’t in the position to say with 100% certainty that it didn’t happen that way, so he couldn’t exactly add a note beside the nurses’ notes saying it was inaccurate. I’m sure he documented that we discussed it and what was documented in the ER wasn’t consistent with how I was presenting at that point in time, but the inaccurate description still lives in my chart. I think there’s a distinct possibility that it could get taken out of context should I be admitted in the future.

The wrong bits in my own chart are pretty small potatoes compared to some of the blatantly wrong diagnoses some people are stuck with. Sure, my diagnosis of borderline traits was wrong, but people don’t generally get overly excited about a diagnosis of personality traits; when people get a mistaken personality disorder diagnosis, on the other hand, that’s likely to stick to them like a bad smell that they’ll never get rid of, because health care provider stigma comes in to play at that point.

I’m not sure what the answer is. There’s a good reason why people shouldn’t be able to go back and change their charting to cover their asses. At the same time, people shouldn’t be haunted forever by misinformation.

So now over to you – have you ever had inaccurate information make its way into your medical record? How did that impact you, and what (if anything) were you able to do about it?