My Medical Records are wrong!

The same thing happened to me Kateykrunch - it was years ago when I went for an appointment and the GP queried something on my medical records - I realised that this was not me. He sent me a print out and apparently I had had several procedures done and even given birth on a date unknown to me!!
When the notes were computerised someone seems to have amalgamated my notes and someone else's. I made the corrections and added a couple of notes that should have been on there and then the GP and I went through it together.
They were very helpful.

You are entitled to see your medical records, Katey and this really does need to be corrected without the PM becoming defensive about it.

I think that people have to be their own advocates in such matters, to be persistent but polite and disarming throughout the process because medical staff are trained to protect the company they work for which places them in a position of being defensive- Even the kindest staffer, if crap hits the fan, will not be on the side of the patient- Their job security means more to them than any patient - Doctors also have to follow company protocol- But doctors have acted as their own advocates and walked off the job when the cost of malpractice insurance skyrocketed - They will not do that for their paitents, however- I currently have a UTI- My doc prescribed medication for it that I cannot take - I went back to the office to discuss it - The staffer wouldn't tell me what kind of UTI I have, and as far as the medicine was concerned I would need to reschedule another appointment to talk to the doc about it - I left a message for the doc to call me back but she did not-

Many years (decades) ago I was pronounced to be allergic to penicillin. About five years ago I had some tests that revealed that I wasn't any more (perhaps I never had been), but of course in the intervening years I had always mentioned the allergy and it was in the hospital records.

Last year I was given a course of intravenous antibiotics based on penicillin, having assured the hospital's medical staff that I was not allergic. On my discharge form I was duly shown as allergic to penicillin, and I pointed this out.

I was in the same hospital again today, and they showed me the treatment form, on which the staff had once more duly copied out the hospital record that I was allergic to penicillin. Aagh!

In the last three years DW and I have been told by a doctor to ignore a letter we were going to receive, and have been told on two occasions that we had received the wrong letter.

The hospital trust in question has a Director of Strategy (of course), and a Communications Supremo to deal with media. But the patients are the most important people to communicate with, and there appears to be no adequate supervision of the written material they receive. Of course, templates are used, but should be of a certain standard, and the correct one in each case.

By the way, indicating on the skin which knee is to be replaced is no joke. There was a training film on just this sort of mistake back in the 1980s. And back in the 1930s my mother knew a dental student who confided that they had removed a full set of teeth from the wrong jaw because the chart was upside down.

Unfortunately the quality of data in medical records leaves a very great deal to be desired. In a past life I used to train practices how to improve their data quality, and you would be surprised for example, the number of patients who had had several hysterectomies (and some of them men!)

In an ideal future world we will all be able to see our medical records online, and request corrections where there are errors. You will never be allowed to correct the data yourself, because legally a doctor needs to be able to say what information was available to them at the time they took a decision.

The technology is there, but the number of practices that haven't allowed it to be switched on, because of worries over viewing third party data or unseen results etc is high.

Are you positive that all the admin staff are aware of that?
Not if the comments regarding admin and typing errors are to be believed.

gabriella Xrays usually have big R’s and big L’s on them so that anyone looking at them is in no doubt which side is which.

X-rays show a photo and when describing left and right you have to take into account that right is left and left is right.
That's probably where the error occured when the report was typed up.

Before both my knee replacements the surgeons came and drew a huge black arrow in marker pen on the knee to be replaced. I was a bit taken aback but was reassuringly told, 'Well you never know...!'

Unfortunately, I, too, have had several experiences of mistakes with letters and recording...both with a long membership of a doctor's practice (25 years) and with a newer one. In the worst case, I received less than desirable treatment from my GP until I discovered a very serious error in a hospital letter to her (which I did not see for six months). Although the responsible consultant has apologised and corrected the mistake, the original badly-wrong letter from him cannot be removed from the file. I have to trust that doctors will always read the later one and I have no idea if both letters survived the transfer to digital or the move to a new surgery.

More recently, I had a problem with checking back opticians' records, vital because they thought they had found something new and serious in my left eye. The opticians were not allowed to share information without me going in person so I eventually managed to visit the old optician who - fortunately for me - showed me that the condition had existed for many years and was recorded but - and it's frightening - I noticed what he did not...that it existed in my^ left eye^ but had been written up in his records as in my right eye. I came very very close to having un-needed treatment in the left and was ever so glad they couldn't just email or fax the information in the first place.

I've always found a huge amount of arrogance and bullishness in terms of medical attitudes to any challenge and the worst has happened when I have not been vigilant on my own behalf. I've also found you need to keep querying and complaining til you get something changed and check for yourself.

It's such a waste of everyone's time and dangerous for patients. If only docs would be a bit quicker to own up or check their facts. Shooting the messanger seems to be their first response though.

I remember going in to hospital 12 years ago for a hysterectomy and at the pre op assessment said they were worried a bit about me being a lifelong smoker ? I have very acute asthma and have never smoked I did ask him to repeat my name and date of birth just in case he had the wrong person!!!!

Not on the GPS side but I think it would probably be easier to tell them what you think is wrong and why. I worked in a GP surgery for 26 years. Data entry mistakes do occur and need to be corrected. Sometimes the hospital is in error, sometimes it is human error, sometimes the error is something that is ineligible. I also know the surgery I worked at received over 300 letters a day, from hospitals, patients, solicitors etc. Basically get to the point. Tell them what’s wrong. Ask them to correct the errors and then if they don’t sort it out , go in and sort them out.

I understand your frustration kateyk, accuracy is important. The practice manager does sound very defensive and incredibly insensitive. Agree with jane, a face to face appointment with the senior partner is a good way forward. Hope it’s resolved soon.

They most likely fear litigation. Why not make an appointment with the senior partner at the practice and discuss with them? I suspect they'll be pretty appalled! Apart from anything else it will give rise to concerns as to the accuracy of all their patients' records.
My sister was a medical summariser whose job it was to summarise the paper records onto computerised ones. A lot of scope for typos or inaccurate guesses by a non medically qualified person. Good luck. Keep us informed as to the outcome.

Hi Jane, it was a print out given to me detailing an xray result, I didnt realise it was a summary until I got home. I admit I had to check my breast when I read it though.

Kateykrunch He's a man and men like to hear it straight - tell him exactly!

I would have told them what they got wrong.

It could be a case of on screen input error. Clicking a box for right breast instead of left.

I am assuming you get a hospital letter confirming the lymphodema diagnosis saying that a copy had been sent to your GP. Maybe it went astray. Often this stuff is being dealt with by receptionist/admin staff and mistakes do occur.

It's frustrating when our health is at stake but sadly that's the way things are now. Don't most of the problems we encounter with hospitals arise out of admin rather than clinical errors? I know mine do.

Wow I find this really scared. Is it due to inefficiency or do they just not care. Why were t you invited in to meet with the PM? I feel that is the least they could have done.

Why did you request this print out? Is there a complaint ongoing? Maybe the practice is feeling a bit defensive? Sounds like the phone call ended up badly with both sides feeling aggrieved.