Medical Records

[GlasweJen]

Is it possible to have a medical record changed? I've suffered for years with a condition called neurocardiogenic syncope, it took them the best part of 3 years to work out what was wrong and we saw on the records during that time that they thought it was in my head (until i almost died during a test) this was despite me fainting while getting bloods done. I decided when i was diagnosed and started getting treated that it was a non issue but last year i started to suffer with chronic fatigue, joint pain, skin rashes and (more recently) migrane. I was referred to a doctor at a edinburgh hospital who told me he thought i had CFS but didn't want to label me (wtf?). He told me he'd write a letter to me and my GP about this alas I never recieved such a letter. I forgot about being cc'd into the letter until I was in hospital seeing my cardiologist and read some of the letter out of boredom, in it the doctor from the edinburgh hospital basically wrote that i was attention seeking and actually lied (he wrote that i danced for 4 hours per day when I quit dancing before the onset of the symptoms). As a result of this no one has ever offered me help with the symptoms which i still suffer, my cardio refered me to dermatology because my skin was a mess but no one wants to help with the joint pain. Can i make them remove the false statements?

[mree]

Is it possible to have a medical record changed? I've suffered for years with a condition called neurocardiogenic syncope, it took them the best part of 3 years to work out what was wrong and we saw on the records during that time that they thought it was in my head (until i almost died during a test) this was despite me fainting while getting bloods done. I decided when i was diagnosed and started getting treated that it was a non issue but last year i started to suffer with chronic fatigue, joint pain, skin rashes and (more recently) migrane. I was referred to a doctor at a edinburgh hospital who told me he thought i had CFS but didn't want to label me (wtf?). He told me he'd write a letter to me and my GP about this alas I never recieved such a letter. I forgot about being cc'd into the letter until I was in hospital seeing my cardiologist and read some of the letter out of boredom, in it the doctor from the edinburgh hospital basically wrote that i was attention seeking and actually lied (he wrote that i danced for 4 hours per day when I quit dancing before the onset of the symptoms). As a result of this no one has ever offered me help with the symptoms which i still suffer, my cardio refered me to dermatology because my skin was a mess but no one wants to help with the joint pain. Can i make them remove the false statements?

 

Your best bet is to firstly get referred to another consultant for a second opinion. Make it clear to him/her that you have seen the letter in question, and point out all inaccuracies. Ask for the name and extension number of the new consultant's secretary, then contact the secretary after the appointment to make it clear that you want to be cc'd on ALL correspondence concerning you. You should also mention this to the consultant during your appointment.

 

Bottom line is yes, you can apply to have inaccurate statements removed from your medical records, but the practitioner who made the inaccurate entry in the records has to agree. If he doesn't agree to do this, a written note can be made against the record stating that you don't agree with the entry. That's why I suggested getting a second opinion - doctors will VERY rarely admit they made a mistake (my GP got me mixed up with another patient and gave me a sick note for an ear infection when I went to her with a cough and was diagnosed with a chest infection - she never even looked at my ears, but refused to amend either my sick note or my notes!), so you'll more than likely end up with a statement from yourself in your notes saying you disagree - this would be strongly backed up by a second doctor agreeing with you.

 

The above advice is based on many years as both a patient and as medical records manager in a hospital, and more recently as a student nurse.

 

For more information, see the Access to Medical Reports Act:

 

Access to Medical Reports Act 1988 (c. 28)

 

and the Data Protection Act:

 

Data Protection Act 1998

 

 

Click my scales if I've been helpful!

[GlasweJen]

My problem is the appointment in edinburgh was December 2006, i went to see my GP after it and she told me I should see a therapist! Needless to say that didn't happen, i went along with it but a locum GP at the practice said I wasn't depressed (well duh) and it all just sort of ended there. The only person who's even hinted at taking it further is my cardiologist but he can only refer me to hospitals in Glasgow as that's where he's based. I could ask for a second opinion but they'll just send me back to see someone else at the infectious diseases unit even though i'm blatantly not contagious.

[JOSH_IOU]

A second opinion is what you are asking for when you ask for the medical records to be checked.

[Gary29]

I don't know if you can make them remove it, but you are entiltled to a second opinon, you can always ask you cardioligist for a consultant to consultant referal. You wont come under the normal week wait as that is for gp to consultant, but you will be seen.

 

I know this as I used to work for medical records and my mum deals with referals for our hospital, both gp and consultant.

 

So you could try that route, if not go to your primary health care trust, they should be able to help you.

 

If it has helped you tip the scales.