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Objective The study compared healthcare utilization and posttraumatic stress disorder (PTSD) symptom trajectories of active duty service members (ADSM) with self-reported PTSD based on whether they had a PTSD diagnosis in the electronic health record (EHR). Methods ADSM meeting study criteria for self-reported PTSD (N = 470) were grouped according to EHR-PTSD diagnostic status. Participants completed PTSD symptom assessments over a 12 month period. We used log binomial regression and linear mixed model to examine predictors of receiving an EHR-PTSD diagnosis and to analyze healthcare utilization and symptom trajectories based on diagnostic status. Results Thirty percent of ADSM with study-identified PTSD had an EHR-PTSD diagnosis. Combat exposure and PTSD severity predicted EHR-PTSD diagnosis. ADSM without the diagnosis were more likely to have an adjustment disorder diagnosis. Participants with an EHR-PTSD diagnosis utilized more healthcare and reported worse PTSD symptoms over 12 months. Conclusions Findings suggest providers are more likely to record PTSD diagnoses for more severe, complex cases. While less severe cases may be less likely to receive a PTSD diagnosis, they may still access and benefit from care. Findings have implications for use of EHRs to describe health patterns and inform practices and policy in the Military Health System.