In our years of reviewing charts, we’ve observed new PCP visits where the clinician assigns diagnoses based on the medications the patient is taking, adds them to the problem list and includes them in the assessment of the visit. Let’s review some specific examples and the perils of this habit on new visits, especially in the absence of old medical records.
The patient is taking Metformin and the PCP diagnoses diabetes. Some patients are good historians and can lay out the sequence of events surrounding the DM diagnosis. It would behoove the PCP to capture as much of this history in the HPI as possible because, in all likelihood, the clinician does not have the necessary information with which to otherwise assess the condition.
- Example #1: Mrs. Smith takes ___mg of Metformin twice daily. This was started two years ago by her prior PCP after two high A1Cs (8.3 and 7.6). She tests her blood sugar daily and reports that fasting sugars usually average 130-150. A fingerstick blood sugar in the office was 86.
- Example #2: Mr. Jones takes ___mg of Metformin twice daily. He does not remember why or when the medication was started by his former PCP. When asked if he is diabetic, he said he wasn’t sure. Mr. Jones does not check his blood glucose, does not have a glucometer and has never been evaluated by an endocrinologist. A fingerstick blood sugar in the office was 86.
Even though the PCP does not have recent lab values with which to assess DM, Mrs. Smith’s diagnosis appears supported by statements about lab values leading to the diagnosis and the patient’s current monitoring habits. In this case, it would be appropriate for the PCP to add DM to the assessment, order new labs and revisit the condition at the next appointment.
In Mr. Jones’s case, the evidence is not so clear-cut. We know that providers may prescribe Metformin for diabetes management, and also for cases of pre-diabetes (ICD-10-CM code R73.03) or even weight loss, so it is not permissible to infer a diagnosis from a medication. The best course of action is to request records from the former PCP – at a minimum, lab records – to establish the legitimacy of the diagnosis.
But what of Ms. Green, who tells her new PCP that she was diagnosed with diabetes many years ago and doesn’t remember when? She takes no medication for it and when asked, cannot remember any other details concerning her self-reported diagnosis of DM. She explains that her doctor at the time advised that she follow a low-carb diet and engage in regular aerobic exercise, which she continues to this day. A fingerstick blood sugar in the office was 86.
In Ms. Green’s case, the PCP has little beyond “the patient said” to support the diagnosis of DM. It’s advisable to obtain records from prior PCPs, specialists or labs in an effort to find supporting evidence of the condition. “Per patient” conditions should be listed in the history and added to the assessment only when the PCP has evidence they are legitimate and has the ability to assess their status (e.g., recent lab or imaging evidence).