Medical Notes - what do all the "DELETED" comments mean?

[penny]

I've just got copies of my medical notes and the most recent, computer ones, have lots of entries where a date is followed by the word "DELETED"; what does this mean? Have there been comments made by a Dr. which have been removed as they might be incimminating for the Dr. or is it just an error in the records?

[ROMM53]

Are these dates all recent? I.e. after you requested a copy of your notes?

[girl66]

I don't know if this is any help but a friend whose son is a medical student does transcribing records from paper to computer and has to delete irrelevant information. For example, if you went in with a boil that doesn't need to be kept on record for decades, however if you had an allergic reaction to the medication that would be kept on record. Could it be this?

[susymac]

I would think it meant there was an entry that you are not permitted to have. There are guidelines as to what you can have and what you cant, even if you ask for it all, you will not get anything that involves a third party (ie social worker, other family member, etc) you may not get access to any mental health records, and you will not get anything that the doctor has deemed could be detrimental to your health if you knew. Read the guidelines given to you when you asked for them for full details.

They could also have removed anything that was written on your records in error, ie belonging to another patient, and could as you say be covering up their mistakes. Problem is you would never find out as it is unlikely they would admit it and would just tell you it involved a 3rd party.

[PinkNinja in reply to susymac]

That's really useful information. Thanks

[GrittyReads in reply to susymac]

AM I misunderstanding soemthing here?? How can that work???

EG: we would be liable for insurance claims being ruled invalid if we had not told the companies about illnesses, but how can we tell them if we don't even know?? Lots of people still don't get letters from consultants sent to them, as well as to their GPs - although from what you are saying the info in these cases would never have been sent to us.

I'm astonished, 'nanny state' or what ????

[Hidden]

I summarise clinical paper records to computer using codes, every code corresponds to a diagnosis and/or ailment or symptom. Normally deleted means there were duplicate codes - every diagnosis has a code - and the systems can't cope with duplicates. I wouldn't ever delete old trivial diagnosis' but might relegate them to the 'background' on the record. Sometimes GP will use inappropriate codes and I will delete that code for a more appropriate one the system can pick up. Using code form means the surgery will get paid for the people it sees and the work it does. I can, and so will anyone who does

the same job, see when those codes were deleted and would be able to figure out why. If codes are deleted without good reason it is a very serious offence and can easily be uncovered by anyone who does the job.

In response to the feeling you won't get third party information or damaging information - the codes wouldn't ever be deleted, they would be hidden and you just wouldn't see what they had to by law keep from you.

[Hidden]

All records on the computer either made or deleted have to be signed (password) by the individual who made or deleted them. They need their password to get into the computer and then their ID is left after each comment/deletion. If you should want to pursue this then the identity of the person concerned should be clearly visible to the Dr or Practice Manager who will know which member of their staff on what day and at what time made or deleted those entries and should be able to answer your questions as to why.

[Hidden]

You would never get them to identify to who who deleted what. I made a complaint about a gp practice and they went back and retrospectively altered the records to protect themselves and cover incompetence. The Ombudsman told me CATEGORICALLY that anti fraud software is not used in the nhs so there would be no way of identifying who did what.

The system is so morally corrupt you just cannot beat it

[Clutter in reply to Hidden]

I believe GP records are audited following the Dr. Shipman scandal to prevent a recurrence of such activity.