A patient has requested a copy of

A patient has requested a copy of her clinical chart to be released to a specialist treating a newly diagnosed condition. The specialist is interested in learning about any previous diagnoses, medications, and allergies the patient has had documented in the past. Upon review of the patient’s record, she notices that the patient has a diagnosis of a poorly functioning thyroid, but there is no evidence of treatment or medications. In discussion with the patient, the patient indicates she was never diagnosed with a thyroid problem. What could have happened in the patient registration process to cause a problem with the clinical record?

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