how to document a off the record request

[Guest guest]

I have a 42 yo wf patient with fibromyolgia, chronic insomnia, migraine and tension headaches came in with a special request that she wanted to be “off the record”.

Per the patient, her husband is a musician with bad temper who drinks a lot of beer and she has not been happy with the marriage for years, but afraid to tell him (she is unemployed). He was given one month samples of Lexapro by his doctor a few months ago. He took none of it. Without his knowledge, she has been grounding the Lexapro and mixing in his beer for a month and “he became a much better person to live with”. She asked me for a prescription of Lexapro in her name or a lot of free samples. I told her I can not fulfill her request because what she has been doing is illegal and unethical and I asked her to communicate with him.

She is asking my office to transfer her record to another office.

Should I document all of this in her record (which her new doctor could see)? Any legal responsibility to report to any agency?

Thank you in advance for your help.

H. Yang, M.D.

Helping your favorite cause is as easy as instant messaging.  You IM, we give. Learn more.