Can a doctor put a diagnosis of Munchausen syndrome in my chart without consulting me?

A fellow caregiver asked...

Recently I have been having problems getting treated or even tested for symptoms I have been having. Today I found out that my previous provider had put a diagnosis in my records that he believes I have Munchausen syndrome. Is it legal for him to do that without consulting me? I believe this is why I am having this issue with my current provider. Any advice is greatly appreciated.

Expert Answer

Kenneth Robbins, M.D., is a senior medical editor of Caring.com. He is board certified in psychiatry and internal medicine, has a master's in public health from the University of Michigan, and is a clinical professor of psychiatry at the University of Wisconsin-Madison. His current clinical practice focuses primarily on geriatrics. He has written and contributed to many articles and is frequently invited to speak on psychiatric topics, such as psychiatry and the law, depression, anxiety, dementia, and suicide risk and prevention.

Munchausen Syndrome is an unusual disorder in which someone acts as though they have an illness, but they are actually causing the symptoms. For example, someone may complain of vomiting or a rash or bleeding, but it turns out they are doing something to cause the problem. People with this disorder can be given multiple surgical procedures before someone realizes the underlying condition. It is generally believed this disorder is a result of someone having significant psychological problems that leads them to crave the special attention given to those who are ill.

Your provider is responsible for helping you treat your symptoms. In order to do that, the first step is to make a diagnosis. Your provider must put in your medical record the diagnosis he or she believes is proper, and they do not have to consult with you to do that. On the other hand, if your provider believes you are not being honest with them and they conclude you have Munchausen's Syndrome, it would be unusual for them to not discuss it with you. If someone has Munchausen's Syndrome, they need help so they can understand their behavior and get proper help to treat the condition. I gather from the way you wrote your question that you disagree with the diagnosis. If that is the case, it is very important that you work with your current provider to clarify the diagnosis so that you get proper help. If you can not clarify the situation with a frank discussion, your provider may ask you to be evaluated by a mental health professional. I would encourage you to do what is asked so in the end you and your provider can work together to get you feeling better.