When There’s Inaccurate Information on Your Psych Medical Record

a doctor writing on a folder
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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?

45 thoughts on “When There’s Inaccurate Information on Your Psych Medical Record”

  1. I’ve had nurses write stuff on my chart about how I was presenting that wasn’t true at all. I only found out about it when the doctor mentioned what they’d written, it wasn’t dr. Barry, just a junior doctor who’d seen me during admission. If it was Dr. Barry she’d know the real story and if she had any reservations she’d talk to me about them, she wouldn’t just believe what was written on paper. Xx

  2. I have no inaccurate info in my notes to my knowledge of any kind, whether mental health related, or anything else, to my knowledge.

    But I know my mum has a slight inaccuracy in her notes from years ago that I can remember mum telling me about and so when she was last sectioned and I received notes about that, which I discussed with her, naturally she wanted to know what it said.

    And that day when I went to the hospital in February regarding her blood, which ended up nothing was wrong. When it came to discharge, I was given the discharge papers for the care home, which I gave mum to read, when she asked what it said. I helped with reading that for, where she was struggling, because it stems for her not trusting because of that incident years ago.

    Her notes of slight inaccuracy that I remembered upset her will still have this and not something my mum ever approached about all those years ago.
    The thing that upset mum was the reason of being voluntary sectioned was because of “may be a danger to herself/others.” It was the “others” part that upset her, because my mum wouldn’t have been a danger to anyone else, only herself. But when I seen those notes, the way they were done and as I explained to mum, felt like a bog standard form that they just didn’t cross out the other part, if you know what I mean.

  3. I hate that there’s such a stigma in general about mental health diagnoses, especially when it’s so common to have charting and diagnosis errors. I hate that difficult=borderline. It takes away from those who DO have it, and it can prevent accurate treatment from those who don’t.

  4. I can’t imagine what my chart looks like. I have literally been diagnosed everything except blatant crazy. I’ve had three documented psychosis episodes which I believe altered my diagnosis this past September. I’ve never seen my chart but I do know it began as MDD but quickly changed to bipolar 1. I can agree with my co-occurring disorder diagnosis because I am self-aware but I am not certain my exact diagnosis at this point. It shouldn’t be that way, should it? I should explore more but perhaps I don’t care to know. Idk. You’ve given me something to ponder as always. ☺️

    1. When I was gathering some of my old records to give to my doctor who filled out my disability application, I didn’t want to look at it, so I got my mom to sort through and figure out what my doctor would need. Everything I do know is because someone else has told me what they read.

  5. Yes! You would think that one advantage of a big, centralised, healthcare provider like the NHS would be that medical records would be centralised and accessible to any NHS doctor, anywhere in the country. Hahahahahah!!!!!

    After I’d been in the system for a long time (not sure how long, probably eight or ten years), it emerged that my psychiatrist didn’t have a record of all the meds I’d been tried on. And by that stage it was a LOT, far more than I could remember, especially as there were a lot of different medication combinations. She said I should have kept my own records (!!!!), no matter that when I’d entered the system I was suicidal and barely functional.

    She tried to pull together a list from what records she did have, but much of it seemed wrong. For instance, she thought my first prescription was a combination of antidepressant and mood stabiliser, which (a) definitely was not what I remembered and (b) would have been a very unlikely opening gambit from a psychiatrist for what at the time presented as a fairly straightforward case of unipolar depression. Crazy.

    1. Yikes. Canada is also a shitshow when it comes to medical records. I don’t know how we’re living in an age where technology can make all of this so easy, but the people running the decision prefer to stick with the shitshow.

      And keeping your own records… that’s quite an odd thing to expect. The GP I’d been seeing never did bother to track down any of my old records until I gave him old discharge summaries to support my disability application. By that point he’d been seeing me for several years but was suddenly scared of me because he found out my history. 🤷🏻‍♀️

  6. Oof, this is such a problem that I’m bound and determined to combat in our mental health system. You know my opinions on diagnosing (on paper) mental health problems, so I’ll focus more on where we are with it haha. Misdiagnosing I find happens WAY more in mental health than we think. The example of difficult=borderline is a beautiful example of this idea creating a stigma. At the end of the day, mental health is subjective. Sure there are some objective observations we can make that limit our functioning, but a lot of what is diagnosed is subjective to the provider diagnosing it.

    My take is I NEVER diagnose on paper because in mental health the diagnosis changes so frequently it just doesn’t make sense to for practical treatment. I’ve seen clients in inpatient who are repeatedly misdiagnosed and re-diagnosed simply because the psychiatrists and social workers didn’t ask enough questions outright. I mean come on! As we learn more, the diagnosis changes. Like you said, it’s next to impossible to erase previous misdiagnoses. Because of this, providers will just leave like 30 mental health diagnoses in a chart for one person. Imagine looking at your chart and seeing all these different diagnoses that may or may not be truly what you struggle with.

    This is why there are such massive problems with misdiagnosis in mental health–we simply do not have efficient ways to diagnose within the constraints of our western biomedical approach to mental health. Our lives are designed around diagnose, medicate/fix, and send away when our brains are so much more complex and deserve way better than that.

    Ugghh, this is a bit of a tricky topic for me as you can see hahaha. This very idea of misdiagnosis is why I’m 100% transparent with my clients (and why I found a therapist who is willing to be 100% transparent with me). You’ve definitely seen way more of this than me, though. I can’t imagine being on the receiving end of a misdiagnosis. I’d probably be called borderline after finding out haha.

    1. It’s an interesting issue. I think some of the time it’s well-intentioned, like if someone with bipolar presents first with a depressive episode, but I think a lot of the time, stigma and poor assessments come into play. The whole model of coming up with a diagnosis after a single assessment seems fundamentally flawed, and billing based on diagnostic codes is even more flawed.

  7. Johnzelle Anderson

    I thought of you as I recorded my latest podcast episode as my guest and I discussed stigma in the helping professions. Check it out if you have time.

  8. My mom told me I was allergic to penicillin & I told doctors that my whole life. During a persistent sinus infection, one asked me why I had put that down. I said I didn’t know but Mom had said. He decided to prescribe it anyway, it cured the infection, and I had no side effects!

  9. Yes it has happened to me. I was a victim on an inpatient unit and the notes made me look like a bad guy. Nothing came of it. I don’t like. I take solace in knowing that God knows the truth.

      1. I don’t know if there are any problems with my records, BUT there are a shite ton of them too! It was part of my final job to work with the new EMR (at the time electronic medical records were brand new). The old paper files were all transferred by hand and you just have to know that mistakes were made. I find it frustrating that one can’t obtain a hard copy of one’s own records. Then there’s the non sharing of information from health care organizations to ‘outside’ organizations. I know that I am someone they don’t want to deal with if I find an error though. Sometimes BPD has its perks! I NEVER mention my mental illness to providers though. Because suddenly they act and treat you differently. If they find out on their own, we can discuss it then.

  10. I went back to a psychiatrist and challenged her on a diagnosis she gave me. Her report, which I requested from my family physician, was filled with inaccurate information.

    After I gave her all the details that she had wrong, she said she was quite surprised to see me back in her office, because in her lengthy career of 25+ years, no one had ever asked to see the reports.
    No one had ever corrected her before.

    I reminded her that it’s important to ask someone for clarification, rather than make all sorts of assumptions and generalizations. I also suggested that professionals should be sending reports to patients for review. Pretty sure that my suggestion went absolutely nowhere but it sure felt good to say that.

    I’m not sure if what I did changed her approach, but it was very empowering for me to do that.

  11. I can’t look at my own records, which pisses me off. I technically can purchase a medical report on myself, but it’s expensive and probably not all the stuff on me.

    I recently saw my current psychiatrist and learned there’s even a weight trend graph using data from the 2 different hospitals I go to.

    Then I asked what exactly are my diagnoses (and held my breath because some doctors don’t like that question) and learned I’ve several.

    That’s just medical reports. My doctors can’t even see my social worker reports, and neither can I. Yes, it bothers me immensely, particularly due to the power of inaccurate information haunting patients decades later.

      1. Yup, and can you believe it… an insurance company can purchase a medical report on me (and I had to consent or not be insured for physical health stuff)… but I can’t see the dang report on me?

  12. I don’t think I’ve experienced this personally. But, i do wonder how done diagnoses can be made in the time they made them- sometimes it seems to be out of laziness or convenience. Complete lack of integrity or care.

    1. I agree, particularly for diagnoses like personality disorders where there needs to be a longitudinal pattern. It’s just not possible to get a clear picture in a single assessment.

      1. Absolutely! Actually, now I think about it, I have had it happen to me. Interestingly, it was for a diagnosis of depression, which I’ve not agreed with. I certainly get states of depression, but it’s secondary to bigger stuff going on- previously unresolved/’untreated’ core issues related to attachment/unmet needs.

        I started articulating this a couple years back, but didn’t know what it was- I just had the sense it wasn’t depression, or there was something much more than that for me. I’m now able to express it and my psychologist now sees what I was trying to say back then.

        1. When a patient disagrees with a diagnosis, I think that should definitely be an indicator to the person making the diagnosis that they need to dig a little deeper. It’s one thing if someone doesn’t have insight because they’re manic or psychotic, but otherwise, they should be asking more questions. It shouldn’t be the patient’s job to say no, this is what’s actually going on.

          1. Yep, I reckon there may have been some thought around me lacking insight, or being in denial. Though, I didn’t fight it that much because I didn’t have an alternative answer. At least now I can identify it 🙂 and both my GP and psychologist agree with me

  13. I can tell about a dozen stories about inaccurate info on my psych records. Most notably though, my most extensive autism diagnosis report disappeared during a transfer from one electronic medical record system to another. After that, rather than saying I needed re-assessing, my psychologist just decided to remove my diagnosis altogether, claiming that because I suffered a brain bleed (which she inaccurately called a stroke) as a baby, I cannot be diagnosed as autistic anyway. Then because I can’t be diagnosed with acquired brain injury and its personality changes in DSM-5, I ended up with just a couple of regular personality disorders. Plus depressive disorder NOS just for insurance purposes, because with just a personality disorder I’d have to be discharged from the psych ward right that day (so the nurses said th e psychologist did me a favor by making that diagnosis and not kicking me out right away). Never mind that personality disorders have their onset in early adulthood, not infancy. That was the only time I myself made use of my right for an independent second opinion, after which I got my autism diagnosis back.

      1. It is. I still get flashbacks to that time and worry that, if my psychologist from that hospital finds out I’m in long-term care now, she’ll try to report me for care fraud or something. After all, the whole point of my PD diagnoses, according to a consultant I later got involved on my case, really was to make it sound as if I were misusing care and to be able to kick me out of the hospital. After all, they were facing budget cuts and I was one of the younger patients and not floridly psychotic.

  14. Over the year’s I have been described as “non compliant”, “refused to be weighed” Much misinformation/ ignorance and a lot of stigma. I requested the “refusal to be weighed” be reworded as harmful to know weight. “Non compliant” I requested to be worded as eating disorder.
    And the best one- “elderly and frail” (a blatant wrong record was ironically the hardest to have removed) despite me being neither elderly or frail 🤣

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