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Dr. Ed Wilfong
Dr. Ed Wilfong, Psychologist
Category: Mental Health
Satisfied Customers: 1528
Experience:  Twenty-five years treating all ages; Specialities: psychopharmacology & diagnosis, MMPI-2, testing.
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GP entry

Resolved Question:

Hello XXXXX sent me to have an assessment for psychizophrenia with a psychiatrist. The assessment started in February 2010 and ended in August 2010. I was diagnosed with schizophrenia in August 2010.

However, my GP made an entry of paranoid schizophrenia and delusional disorder in my medical records in April 2010.

I would like to know;

Is is right that my GP made this entry in my medical records in April 2010 although I was not diagnosed with this condition until August 2010?
Submitted: 2 years ago.
Category: Mental Health
Expert:  Dr. Ed Wilfong replied 2 years ago.

Dr. Ed Wilfong :

This is more of a judgment call. Your GP likely was fairly sure of diagnosis in April. It would also not take the psychiatrist that long to make the diagnosis, so likely the psychiatrist communicated the diagnosis by April. If you are uncomfortable with this, you have the right to request that the medical records be corrected. Since the GP entered the subtype of schizophrenia, you could ask that it be amended to be consistent with Psychiatric report. Also, if the April diagnosis was made without input from psychiatrist you could ask the GP to change it to a "working diagnosis" or "provisional diagnosis". I would talk to GP informally before submitting official request.

Customer: replied 2 years ago.
Thank you for your response.

However, during an appointment with the psychiatrist on 13 April, I asked what her thoughts were on my mental health. The psychiatrist told me from a depression and anxiety point of view I was doing well but she was wondering if something was going on that is bothering me and affecting my mental health.

She asked me to attend another appointment with her to which I replied "ok, but can you tell me what that appoinment is based on?" She replied "well that's what we do here."

Therefore,

1. She did not indicate to me that I was schizophrenic and did not tell me what the further appoinment was based on; so how could my GP make such an entry?

2. There is a cluster of symptoms that must be met for a diagnosis of schizophrenia and the psychiatrit's report does not give any evidence of diagnostic criteria symptoms so how could I be diagnosed with this condition?

Is this right?
Expert:  Dr. Ed Wilfong replied 2 years ago.
It sounds a bit sloppy in documentation, but legally, both GP and Psychiatrists are licensed to make the diagnosis. You can still request that the record be amended or detail added as you are correct, the symptoms should have been noted. They can make the diagnosis and note it -- it does not mean they are correct. I do not know the procedure for you to ask to amend record, but you should have that right. You should have some sort of patient advocacy system to help you with this. If you are asking if it is malpractice or illegal, the answer is no. Poor judgment by MDs, likely.
Dr. Ed Wilfong, Psychologist
Category: Mental Health
Satisfied Customers: 1528
Experience: Twenty-five years treating all ages; Specialities: psychopharmacology & diagnosis, MMPI-2, testing.
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