Investigating Misleading Medical Documentation Related to Psychiatric Medication Use During Pregnancy by Samiha Saifudeen
Updated: May 29
Recently, concerns have been raised about medical discharge paperwork given to mothers who used psychiatric medications during pregnancy, especially medications such as Sertraline. According to Dr. Waggel, some mothers with completely normal deliveries discovered wording in their discharge notes that suggested “complications due to maternal psychiatric medication use,” despite there being no actual complications during labor or delivery. This wording caused
emotional distress and confusion for patients.
This topic is important because inaccurate medical documentation could negatively affect research quality, patient trust, emotional wellbeing, and possibly even future healthcare decisions. However, it is also important to clearly state that the exact reason for this wording has not yet been confirmed. Multiple possible explanations exist, but more investigation is needed before drawing conclusions.
Dr. Waggel, who works with pregnant patients taking psychiatric medications, noticed this issue after hearing concerns from mothers reviewing their discharge paperwork. Some patients felt guilty or ashamed after reading phrases that implied their medication caused complications, even though their births were healthy and uncomplicated.
One medication frequently mentioned was Sertraline, an antidepressant commonly
prescribed during pregnancy. Dr. Waggel explained that many patients who continue psychiatric medication during pregnancy experience positive mental health outcomes and healthy deliveries.
Despite this, discharge paperwork sometimes included language suggesting
complications associated with maternal psychiatric medication use. Dr. Waggel began reviewing full patient medical records and discussing the issue with other physicians to better understand why this wording appeared.
One commonly suggested explanation is that the wording may be connected to medical billing codes rather than actual complications. Several physicians suggested that hospitals may use diagnosis codes indicating that a pregnancy was “complicated by psychiatric medication use” simply because the patient required additional monitoring.
Some doctors stated that current coding systems may not have a better option available. Instead of saying “monitoring for possible complications,” the code may automatically imply that a complication already existed.
Other physicians suggested the possibility of “upcoding,” where documentation may appear more severe in order to increase billing complexity. However, there is currently no evidence proving fraud or intentional dishonesty.
It is extremely important to state that these ideas are only theories and have not been verified.
Another possible explanation discussed by physicians is the increasing use of artificial intelligence and automated charting systems in healthcare. Some doctors reported seeing AI generated documentation adding diagnoses or phrases that providers did not intentionally write themselves.
If AI systems are incorrectly inserting language related to complications, this could create inaccurate records without physicians fully realizing it. Again, this possibility has not been confirmed and requires further investigation.
A few physicians questioned whether broader social or political movements against
psychiatric medication could influence documentation language. Some specifically mentioned concerns about increasing criticism of psychiatric medications in public discussions.
However, there is absolutely no proof connecting these documentation issues to any political movement or public figure. Even Dr. Waggel stated that this idea may simply be a conspiracy theory. Because of this, it is important to discuss this possibility carefully and without making unsupported claims.
One major concern is the emotional effect on patients. Mothers reading that their
pregnancy was “complicated” by psychiatric medication may feel guilt, fear, or shame, even when both the mother and baby were healthy.
Pregnancy already causes significant stress and anxiety for many women. Misleading wording may worsen mental health and create unnecessary worry about medication decisions that were medically appropriate.
Another important issue is the effect inaccurate documentation could have on scientific research. Researchers rely heavily on medical records and diagnosis codes when studying pregnancy outcomes and medication safety.
If records incorrectly classify healthy pregnancies as “complicated,” studies may produce inaccurate conclusions. This could potentially exaggerate risks associated with psychiatric medications or other medications used during pregnancy. As a result, future healthcare recommendations could become less reliable.
Patients expect medical records to accurately reflect their experiences. If mothers
discover documentation that does not match what actually happened during delivery, trust between patients and healthcare providers may be damaged. This could make patients less likely to trust medical advice, ask questions, or feel comfortable discussing mental health concerns in future pregnancies.
To better understand this issue, I conducted an informal investigation online. This
investigation was not scientific research and should not be interpreted as proof of any conclusion. I reviewed Dr. Waggel’s video, read physician discussions about medical coding, looked at discussions on Reddit and Quora and researched medical billing and diagnosis coding systems.
Several online users reported seeing confusing or alarming wording in discharge notes despite normal deliveries. Some healthcare workers explained that diagnosis coding systems often prioritize billing and insurance classification rather than patient-friendly wording. Others stated that automated charting systems and AI generated notes may contribute to documentation errors. However, no single explanation was confirmed. Many responses were personal opinions or experiences rather than verified evidence.
Works cited
Thank you for sharing this important topic! I think it is concerning that medical documentation could cause unnecessary stress or guilt for mothers who took psychiatric medications during pregnancy, especially when their deliveries were otherwise healthy and uncomplicated. I appreciate that you explored several possible explanations while emphasizing that none have been confirmed. Accurate medical records are essential not only for maintaining patient trust but also for ensuring that future research on medication safety during pregnancy is reliable. This also highlights the importance of clear communication between healthcare providers and patients so that women feel supported rather than judged for prioritizing their mental health. I would be interested to see further research into how medical coding and automated documentation systems…
There needs to be more research done to avoid these misleading documents from showing up. They can create a lot of fear about the healthcare field.
It’s nice to see that doctors like Dr. Waggel are taking the time to look into this issue, because otherwise patients may be confused and misled about their medical treatment and condition
While hospitals may think of medical records as simply a way to optimize their billing, they need to realize the impact it has on patients' emotions and future research.
Wow, really thorough investigation! Misleading wording can cause emotional stress and confusion for the mother while increasing distrust in healthcare. AI adding diagnoses to documentation only worsens this issue