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May 27, 2018 01:36PM
May 27, 2018 01:43PM
If you google, "the patient denies", you will find a long discussion among student doctors about the use of that term in medical records. (On the other hand, if your doctor actually wrote that you were "in denial" that would be another story.)
I copied a couple of excerpts:
A) "I accompanied an elderly parent to a neurologist appointment recently. As this was at a teaching hospital, the first meeting was with a resident who took a complete history and did an examination. When the neurologist came in, the resident verbally reported the results of his history-taking as "The patient reports a sense of imbalance on standing. The patient denies feeling dizzy." etc. As my parent had few symptoms, the list of denials was quite long.
The use of 'denies' has a clear meaning in this medical context ("On being asked about symptom X, the patient said that they did not experience it"), but for the patient it carries unpleasant overtones (accusation, disbelief)."
B) " it also serves as documentation that you actually asked the patient about the symptom or situation that they did not experience.
Here's how it was explained to me:
For example, the first time you get sued for Failure to Diagnose a SAH, and you document "The patient has not had a headache," their attorney will stand up and make a big point about how the patient actually DID have a headache, you just never asked about it. And from your documentation, it admittedly is not clear that you did. You may have simply assumed the patient had not been experiencing a headache.
However, if you write, "The patient denies having a headache," you can successfully argue that, according to your documentation, you did in fact ask if the patient had a headache and they said no.
In addition to the above, it also serves as documentation that you actually asked the patient about the symptom or situation that they did not experience."