Trying to get hold of my full medical notes - what do I do please?

[brian48]

I am just starting on the road to recover missing medical notes which i received in 2013 after reading them i consulted a solicitor, when he sent for the notes the vital note was missing, any ideas.

[SHIRLI]

I am just starting on the road to recover missing medical notes which i received in 2013 after reading them i consulted a solicitor, when he sent for the notes the vital note was missing, any ideas.

 

 

 

GOOD AFTERNOON brian48

you say you received missing medical notes in 2013 I presume this included the missing notes although when your solicitor sent for your medical notes some were missing am I understanding you correctly when I presume you already have the missing notes or are there several more that are missing

[honeybee13]

Hello Brian and welcome to CAG.

 

I've started a new thread for you because it's better to keep advice for each cagger separate. Please continue to post on this thread.

 

My best, HB

[rebel11]

Hi brian48

 

Here's some information:-

 

http://www.nhs.uk/chq/pages/1309.aspx?categoryid=68

 

If you've already sent a SAR request, send a chase letter giving them a deadline to fulfil the SAR request.

[think about it]

Brian, where are the notes held?

 

Can you tell us how you first came to see your notes, whether it was held in paper form or electronic. Equally was the note a record of a GP consultation or from a clinic/hospital?

 

Did your solicitor request a copy of all records or just those held electronically?

 

Lastly, have you changed surgeries since last year?

[SHIRLI]

Brian, where are the notes held?

 

Can you tell us how you first came to see your notes, whether it was held in paper form or electronic. Equally was the note a record of a GP consultation or from a clinic/hospital?

 

Did your solicitor request a copy of all records or just those held electronically?

 

Lastly, have you changed surgeries since last year?

 

 

I think the time as come to number every page and entry of medical records in chronological order why this has never been done before is a disgrace

[think about it]

Shirli, They way that records are stored currently, and how they're likely to be stored for some considerable time yet makes numbering each page totally impractical. In fact, based on the way they are held it'd actually be easier to remove a numbered page from a stack than it is currently to do so.

 

I've asked the questions I have to help Brian locate the entry in question.

 

As soon as I hear back from him I'll elaborate.

Edited November 12, 2014 by think about it
Auto correct does nothing of the sort

[brian48]

hi shirli i sent for the medical notes in 2013 when i received them there was damaging notes to the surgeon that sent me for a second opinion, but the thing is i have misplaced the notes, again they have removed the notes before they sent them to the solicitor so i am trying to recover them.

I am in contact with the legal aspects team that sent them to me, they havent replied up till now tho.

[think about it]

Brian, if you can answer the questions in my earlier post I may be able to help.

[think about it]

Brian,

 

there's good reason I'm asking the questions I have and whilst I don't really have the time to go through every possible situation there's a couple of key things worth bearing in mind.

 

If your solicitor had requested the records from your GP, one or two other things may be at play. Firstly, ensuring that they've requested FULL copies of your notes including photocopies of all paper notes that are held. Quite often requests come in only for copies of patient's electronic notes and it may be that there's just a short note saying 'Letter received from hospital re: xxxxx' and not the detail you require.

 

The reason I ask where you first saw the letter in question is to help narrow down how to get another copy, it's unfortunate that you've somehow lost your copy but there's no real reason why another can't be obtained.

 

Secondly, if I read your posts correctly, it's from a consultant surgeon. What you don't say is where you got the copy of your notes from, or indeed where your solicitor requested the copy from. So, it's entirely reasonable that your hospital notes will contain these details whereas your GP notes will not. We GP surgeries get to hear of patients' hospital treatment by way of a discharge letter - a couple of lines along the tune of: "Patient was admitted, xxx surgery was successfully carried out, future treatment plan is xxx, we will review patient in x months. Please continue on x medication".

 

However, the hospital will hold far more detailed records of your treatment. The NHS does not, as yet, have a system in place whereby the GP can freely access the hospital records and vice versa. Will it happen? Probably, but not for a while as yet.

 

So, that means that Shirli's suggestion of chronologically sorted, numbered pages of a complete record doesn't work, yet.

 

Therefore, directing your request to the right people is key in getting the type of information you need.

 

In 'GP land' your records are stored in two ways, firstly the paper records that you've accumilated over the years are still here, however there is also a computerised record which is used on a day to day basis and for any further updates. I asked if you'd moved surgeries, if indeed the first set of notes came from your surgery, because your paper notes are summarised onto the electronic system. That means a very broad overview of conditions and medications are entered, not individual documents. They are of course available in paper form should they be required at any time but not copied out word for word on the computer.

 

That said, if you've not moved surgeries, it's 'possible' that the hospital letter you refer to was copied to the surgery and if so, it may have been scanned onto their system so if you don't get any joy from the hospital ask your solicitor to speak to your GP surgery.

 

One thing is absolutely clear, we CANNOT remove records from the computer without leaving an audit trail a mile wide. Even then, the record is not deleted, just held as inactive so that it can be retreived if needs be. An example of this might be where an entry was incorrectly added to a patient's record - the delete function does several things. It first prompts the user for a reason, adds this reason to the record along with the 'deleted' information and then alerts the system administrator - all the while logging each action in the audit trail. If you believe something has been deleted, ask to see the audit trail. It's for that reason that replacing a 'numbered page' would be remarkably easy in comparison to making changes on the current GP system.

[brian48]

thanks think about it, think your last suggestion might be next way forword. Basicly what it is,,,i read requested my medical records then when i consulted a solicitor when he requested medical records the entry in question was not in the medi records he requested