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<p>[QUOTE=&quot;Aviator305, post: 3029417, member: 25115&quot;]It is absolutely necessary for a doctor to</p><p>“muse” and “think out loud” in a medical record provided that appropriate qualifiers are included such as “possible” and “rule out.”&nbsp; Without such freedom, it would be difficult for one doctor to communicate to another doctor what is being considered in the differential diagnosis. A medical record is not the place for a doctor to shield his/her thoughts.</p><p><br /></p><p>Medical records a started fundamentally as a vehicle by which doctors record data about the chief complaint for a given visit, history of present illness, physical exam findings, past medical and surgical histories, medications, lab and (and now more than ever radiological) data and a general assessment and plan. The final diagnosis is rarely ever possible on the first or even initial set of subsequent visits, and it is entirely appropriate for a doctor to write down possible unconfirmed diagnoses (actually, this is often helpful if not required to justify ordering additional tests for the work up, and the insurance companies will not approve otherwise).</p><p><br /></p><p>As a physician, I am completely sensitive to this issue (and frustrated too), but the problem lies with how YOUR medical record is being used inappropriately by different agencies. Another case in point, one of my very good friend’s life was delayed by 8 years because of a “question” of a possible renal stone on an x-ray. If the radiologist in good conscience could not exclude a stone on a poor study and recommends a follow up, then the medical examiner should have followed up with the appropriate test before flagging him as not fit to fly.&nbsp; Instead of fulfilling his lifelong dream to fly for the Air Force, he had to go through a years-long drawn out process before he was cleared and thankfully is now flying for the Army.[/QUOTE]</p><p><br /></p>

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