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Re: Know your diagnoses?

Posted by Racer on March 20, 2004, at 19:25:42

In reply to Know your diagnoses?, posted by lonelygirl on March 20, 2004, at 12:23:50

The whole diagnosis thing came up for me because my therapist had to transfer me to another within the same agency, and this new one is hung up on Diagnosis. Not enough to need professional help, everything has to be pathologized. That's not very helpful to me, so I did ask to see my chart, and got my Official Diagnosis from it. (DSM IV uses a multiaxial diagnostic structure, with primary psychiatric diagnosis on Axis I, personality disorders or mental retardation on Axis II, Physical Health on Axis III, situational factors on Axis IV, and Global Assessment of Functioning on Axis V. My Axis I is Major Depression, Axis II is Not Found, Axis III is osteoarthritis, Axis IV I haven't found out the code list for, and Axis V is moderate functioning. Does that make sense? It does to me, and knowing that does help me. For some people, though, it might actually be detrimental to see those things. I think it's an individual thing.)

As for trouble getting the chart, that's another issue altogether. In California, we have the right to request the chart. In California, the doctor has the right to say that complying with that request would result in detrimental or adverse consequences for the patient, and refuse to comply. If you do ask to see it, be aware that it may not be positive for everyone, and that it might be best to discuss the issue with your therapist rather than simply saying, "show me!" (I know, I'm a "Show Me!" kind of gal myself, so it's probably stupid of me to say that.) Also, the doctor may choose to provide you with a summary, rather than the whole chart. That's also allowed.

Notes are a touchy subject, for a lot of good reasons ranging from the 'what if someone else sees them?' type, to the 'it interferes with patient rapport' type. If your therapist remembers things from week to week, and you're satisfied with your relationship, I wouldn't worry about it. My former therapist didn't take notes in session, and her notes in my chart were to the point, detailed enough without disclosing anything I wouldn't want to hear read aloud in public, and generally toeing the line of thoroughness versus exposing. I hope that makes sense.

Good luck, whatever you decide.




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