Diagnosis of PTSD by Army Behavioral Health Clinicians: Are Diagnoses Recorded in Electronic Health Records?

ABSTRACT

OBJECTIVE: The study sought to identify the extent to which posttraumatic stress disorder (PTSD) diagnoses are recorded in the electronic health record (EHR) in Army behavioral health clinics and to assess clinicians' reasons for not recording them and treatment factors associated with recording or not recording the diagnosis. METHODS: A total of 543 Army mental health providers completed the anonymous, Web-based survey. Clinicians reported clinical data for 399 service member patients, of whom 110 (28%) had a reported PTSD diagnosis. Data were weighted to account for sampling design and nonresponses. RESULTS: Of those given a diagnosis of PTSD by their clinician, 59% were reported to have the diagnosis recorded in the EHR, and 41% did not. The most common reason for not recording was reducing stigma or protecting the service member's career prospects. Psychiatrists were more likely than psychologists or social workers to record the diagnosis. CONCLUSIONS: Findings indicate that for many patients presenting with PTSD in Army behavioral health clinics at the time of the survey (2010), clinicians did not record a PTSD diagnosis in the EHR, often in an effort to reduce stigma. This pattern may exist for other diagnoses. Recent Army policy has provided guidance to clinicians on diagnostic recording practice. An important implication concerns the reliance on coded diagnoses in PTSD surveillance efforts by the U.S. Department of Defense (DoD). The problem of underestimated prevalence rates may be further compounded by overly narrow DoD surveillance definitions of PTSD.