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GP records

(33 Posts)
coco12 Wed 02-Aug-23 07:30:31

Morning all.
I've recently got full access to my medical notes and was a bit shocked to find that there is a full transcript of my counselling sessions from many years ago. I'm due to see a counsellor again and it's put me off a bit. I'm a very private person and didnt realise the full chapter and verse would show on my notes.
If anyone has worked for a GP do you know who can see these notes, can a doctors receptionist for example? I think it was more a shock to me to see my feelings laid bare for myself to read if that makes sense. But I'd like to think it was between the counsellor and me.
Thanks for reading

Allsorts Wed 02-Aug-23 07:39:50

It’s always bothered me but there’s nothing you can do I’m afraid. If people have access to records you have to hope they are discreet.

Shelflife Wed 02-Aug-23 08:17:05

Like you I have always assumed that counselling sessions were strictly confidential!

Iam64 Wed 02-Aug-23 08:22:11

Counsellor records are confidential, so like you I’m surprised to read you found a full transcript in your GP records. I’d have expected a brief summary but I haven’t worked in the nhs.
Maybe this is an issue for you to explore and clarify during your first meeting with the therapist you’re due to meet with

Salti Wed 02-Aug-23 08:41:54

I don't like this either. The variety of people who can see patients notes seems to be ever expanding. At a recent physiotherapy appointment at the surgery the physiotherapist made a comment that led my brother-in-law to realise that he had access, nurses too and when I got a dog bite and needed to know when I'd last had a tetanus injection the receptionist looked it up.
I used to believe that they were only accessible to my doctor and that's the way I'd prefer it.

coco12 Wed 02-Aug-23 15:08:25

Iam64

Counsellor records are confidential, so like you I’m surprised to read you found a full transcript in your GP records. I’d have expected a brief summary but I haven’t worked in the nhs.
Maybe this is an issue for you to explore and clarify during your first meeting with the therapist you’re due to meet with

So I've been back and read it all again and I was a bit unfair in saying full transcript so sorry to mislead but it did have a full description of my general thoughts and some things that I had said. I think I will definitely ask my future counsellor what the procedure is. Its unsettling though...

Casdon Wed 02-Aug-23 15:26:32

Just a thought, but was the counsellor you saw attached to your GP practice? If so the file with her summary of your counselling sessions would form part of your GP records (as a folder), so it maybe that when you asked for your GP records it was opened and included for your benefit? I’d be surprised if it wasn’t password protected if that was the case.

coco12 Wed 02-Aug-23 15:33:51

I'm not sure actually. It was my GP at the time that organised the counselling so that may be the case.
I just need to accept it really as on the whole I would rather see my notes than not. And silly as it sounds, this information has been there for years.. I just didn't know about it. This is one of the reasons they stipulate you may be subject to things on your notes that could be upsetting etc.. and you sign to say you've understood.

Primrose53 Wed 02-Aug-23 17:01:10

A receptionist was sacked at our GP surgery a couple of years ago because she accessed patients records of hundreds of people who she knew, friends, neighbours, relatives etc. her excuse was she did it when she had nothing else to do.

coco12 Wed 02-Aug-23 17:14:57

All that private information! 😕

seadragon Wed 02-Aug-23 17:20:57

As a student social worker I spent some time helping an individual to come to terms with her complex grief over the death of her sister. I was required to produce detailed notes for my assessment an had made her aware of this. I went through my recording at the last meeting we had. She said she found the sessions beneficial and that reviewing the process via the notes had also been very useful but did not want them kept on record. I agreed with my practice teacher that I would put a brief summary on the notes that counseling sessions had been held including the individual's comments which she said was fine with her. This was in 1986(!) and based on the practice of Priestley and Maguire - 2 probation officers whose work I admired.

Visgir1 Wed 02-Aug-23 17:42:28

If the GP requested the original counselling via the NHS they will get a full report back.
It's a stackable offence to share that confidentiality outside of the professional capacity.
However you are always entitled to a copy of the letter being sent to the GP just ask the Doctor or Therapist to send you a copy.
Done frequently where I work, so patients fully aware of the plan.

lilypollen Wed 02-Aug-23 18:19:43

It used to be that what was said in the Dr's surgery stayed within the four walls. Alas no longer, change for the worse and not the better and shocking the practitioners who can see them. Mind you the dentist demands to know a lot on their questionnaire. Just fill my *** tooth!

coco12 Wed 02-Aug-23 18:32:44

Yes you can only hope they are true to their obligations of confidentiality.

watermeadow Wed 02-Aug-23 18:44:56

At one time we were handed our medical records to take into the GP. In the waiting room, after glancing through, I realised I’d been given the records of someone else with the same common name. Another time I found that my young child’s records included entries for a sibling and for a middle aged man!

Sawsage2 Thu 03-Aug-23 13:17:59

When I worked on GP'S Recep 8 years ago a patient could pay to see their medical record.

JdotJ Thu 03-Aug-23 13:58:37

A lot of surgeries no longer hold the Lloyd George notes (buff coloured envelopes) on site. They're kept elsewhere depending on which part of the country you live.
Any piece of paper ascertaining to you, the patient, will be scanned onto your notes. This means anyone that has log-in access to your screen, inc receptionists, nurses, Health Care Assistants etc etc, can read your scanned on notes.

grandtanteJE65 Thu 03-Aug-23 14:17:57

Medical records, tax papers and other legal papers are confidential, so no, we do not have to hope that those who read them in the course of their work are discreet.

They have signed confidentiality clauses and can be fined and dismissed from their jobs if they tell anyone what they have read or heard about any of us in the course of their jobs.

I realise this probably does not console you very much, but you are certainly justified in asking a new therapist whether everything you tell her goes into notes that any health professional can read. Perhaps you and she can address the issue of why most of us feel more embarrassed by emotional problems we have sought professional help for than physical ones.

Would the thought of health professionals reading full notes on a gynaecological or orthopaedic problem worry you so much?

You felt you had a problem and sought help for it - that is something to be proud of, not ashamed of, after all.

Vintagegirl Thu 03-Aug-23 15:13:00

My husband's GP was closing his practice and returned his patient notes to him with no warning. He was upset to see comments of surgeon who performed difficult operation which were intended for the GP's eyes only. Surely there is a need for a confidential section for the professionals to exchange information?

Callistemon21 Thu 03-Aug-23 15:22:51

watermeadow

At one time we were handed our medical records to take into the GP. In the waiting room, after glancing through, I realised I’d been given the records of someone else with the same common name. Another time I found that my young child’s records included entries for a sibling and for a middle aged man!

watermeadow When I phoned and spoke to a receptionist several years ago I was puzzled when she mentioned a medication she insisted I was on, which I knew I was not. I asked for my notes and it turned out there was another patient with the same name and many of her records were mixed up with mine including her operations and medication. The GP (now retired) promised to sort it all out.

However, recently I picked up a repeat prescription from the chemist and received hers as well as my own.

Jess20 Thu 03-Aug-23 15:40:54

I've previously completed a form for records not to be shared, it was when things first went onto an electronic system. My concerns were that the info was mine and I didn't want it sold or shared without my permission. I'm not sure if that still holds because I've found services outside of my GP who could find out a few things about me, quite limited though, I think there are summary records apart from the full ones. The problem with too much information about you is that if you can get labelled with something and if it's immediately available to the next doctor who sees you they may make assumptions and not look beyond it. I'm a carer, which you would think was a good thing to have on your records but no, some GPs have been very dismissive and treated me as if I'm stressed and anxious and looking for support rather than ill and looking for medical care. Personally, I would ask your GP manager to tell you who the ' 'confidential' counseling notes are available to, and possibly have them removed from view. I would not expect counseling notes to be available as you were probably told it would be confidential - unless there was something that suggested a risk to life. I think this might even be a breach of professional conduct to be honest. My friend is a professional counselor and holds her notes for a limited amount of time after its finished and then destroys them. They are not shared, not even a summarised version.

GoldenAge Thu 03-Aug-23 15:59:35

Coco12 - I’m a psychotherapist - private practice and working also voluntarily in an NHS setting. First of all your sessions should not be recorded which means that no verbatim version should ever be available. Secondly the counsellor will have made some notes and then possibly expanded them to create some sort of record but it couldn’t possibly be word for word. Thirdly those records are supposed to be confidential. I would suggest that at your first session you ask the questions - what does the counsellor do with anything s/he writes about you and who has access and why. You’re perfectly entitled to have these questions answered and if you’re not happy and you want counselling think about going privately because counsellors in private practice must abide by the code of ethics of their professional body and that includes safeguarding personal information. In my case I write notes after each client on a computer that only I have access to and nobody at all sees them. Nor can I be compelled to reveal them except in very rare circumstances by a court. I’m sorry you found a transcript of previous counselling - this must have brought back some difficult memories. Something else to consider is that trainee counsellors are often involved in the counselling provided by GP surgeries and you might feel you want someone qualified Go to the BACP Counselling Directory or the Psychology Today Directory for some ideas

coco12 Thu 03-Aug-23 17:10:22

grandtanteJE65

Medical records, tax papers and other legal papers are confidential, so no, we do not have to hope that those who read them in the course of their work are discreet.

They have signed confidentiality clauses and can be fined and dismissed from their jobs if they tell anyone what they have read or heard about any of us in the course of their jobs.

I realise this probably does not console you very much, but you are certainly justified in asking a new therapist whether everything you tell her goes into notes that any health professional can read. Perhaps you and she can address the issue of why most of us feel more embarrassed by emotional problems we have sought professional help for than physical ones.

Would the thought of health professionals reading full notes on a gynaecological or orthopaedic problem worry you so much?

You felt you had a problem and sought help for it - that is something to be proud of, not ashamed of, after all.

You're quite right, I wouldn't care as much about a physical problem.
I will definitely be looking into it more before my next sessions.

coco12 Thu 03-Aug-23 17:13:19

GoldenAge

Coco12 - I’m a psychotherapist - private practice and working also voluntarily in an NHS setting. First of all your sessions should not be recorded which means that no verbatim version should ever be available. Secondly the counsellor will have made some notes and then possibly expanded them to create some sort of record but it couldn’t possibly be word for word. Thirdly those records are supposed to be confidential. I would suggest that at your first session you ask the questions - what does the counsellor do with anything s/he writes about you and who has access and why. You’re perfectly entitled to have these questions answered and if you’re not happy and you want counselling think about going privately because counsellors in private practice must abide by the code of ethics of their professional body and that includes safeguarding personal information. In my case I write notes after each client on a computer that only I have access to and nobody at all sees them. Nor can I be compelled to reveal them except in very rare circumstances by a court. I’m sorry you found a transcript of previous counselling - this must have brought back some difficult memories. Something else to consider is that trainee counsellors are often involved in the counselling provided by GP surgeries and you might feel you want someone qualified Go to the BACP Counselling Directory or the Psychology Today Directory for some ideas

Goldenage just wondering do you send a summary to the surgery for your NHS patients?

DaisyL Thu 03-Aug-23 18:21:07

Accessing anybody's notes without a proper reason is a very serious offence and everyone who works in the NHS is told in no uncertain terms that anyone discovered doing so will be dismissed. I volunteer at our local hospital and sometimes have to access records of people I know but I would never breathe a word of this. On one occasion I was booking an ambulance for a patient and there was another volunteer having a cup of coffee in the office and even though I didn't mention the patient's name I was told I should have asked her to leave the office while I booked the transport because she didn't work in admin.