My GP practice has now given us access to medical records via patient access. I went through mine yesterday and was dismayed at how many times various drs in the practice have referred in their notes to my ‘hyperthyroidism ‘.....I was diagnosed with hashi 2 years ago, I have hypothyroidism. My regular GP, 8 weeks after telling me I am hypothyroid, recorded next to follow up blood test (8 weeks after I’d been taking levothyroxine) ‘sub clinical hyperthyroidism ‘.
It’s no exaggeration to say we really are managing our own conditions. I can’t even be bothered to tell them they’ve got it wrong.
I’m sadly unsurprised by this... but really?
LULU
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Lulu_65
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If you had a blood test which showed below range TSH doctors would record this as subclinical hyperthyroidism, even if you are hypothyroid and taking levothyroxine.
The thing you've got to watch out for and be prepared for is a doctor who decides your Levo needs to be reduced because of low TSH.
I have got a copy of a "referral letter" to a consultant that was done about 18 months ago. It's not exactly a letter but a form with boxes filled in, some free text to describe the reason for referral and then risks/warnings/allergies/intolerances plus lifestyle information, past medical history etc.
On this referral it shows that
1) I have an adverse reation to tetanus vaccine - actually I have never had a tetanus vaccine, it's my adult son who had the allergic reaction to a tetanus jab but he does use the same surgery so I suppose male and female names can get mixed up as can addresses (it wouldn't if I was doing that job!).
2) I have glaucoma - well actually, that's not me, it's my cousin who lives a couple of hundred miles away.
3) My hypothyroidism started in 1997 - er no, it actually was diagnosed around 1975.
4) One consultation with GP states "Had a chat to patient". Well, that's informative!!!
Doesn't exactly instill confidence in my surgery or the doctors or the correct information being passed on.
We don't have patient access here in Wales at the moment but I do wonder what else in on my record but not really sure I want to know!
I'm struggling to understand how "Had a chat to patient" can provide anything useful on your records, let alone if you see another GP, what can it possibly tell them. They're all very quick to scroll through what's on their computer screen and tell me that my TSH is suppressed and you probably don't need Levo (!!! eye rolls !!!) but nobody has ever questioned the chat to patient entry!! I didn't realise it was so common, I thought it was just my lazy doctor. I've even tried to think back to the date and try and remember what it was, the only thing that comes to mind is that I asked for a referral to one of the popular private doctors at the time (Dr P or Dr S maybe).
I totally agree. It’s a complete disgrace. I work as a paralegal and have to make notes of what is said in court.... if all I wrote was ‘judge had chat with barrister’ I wouldn’t last long in my job.
It's not even good grammar! Had a chat WITH patient, or had a talk TO patient. I would have thought you needed a decent level of English to get into med school.
I'm an absolute terror! I have to sit on my hands, most of the time, so as not to correct grammatical errors on Facebook! The worst for me is 'should of' instead of 'should have'. That gives me a physical pain!
I commented on something the other day, saying I didn't think it was funny, and I objected to the over-use of the word 'hilarious' for something as unfunny as that. And someone replied to me : You may not think it funny, but you don't gotta bitch and moan about it'... I leave you to imagine the reply. lol
Perhaps that's why they're so bad at communication. After all, the point of grammar is that it makes sure we're all singing from the same hymn sheet, and understand each other.
Gotta jump in here! In the ER at my hospital I've noticed that they have a 'solution' to this problem. Because doctors are busy taking care of you, they don't have time for all this documentation. So when they see you, another usually younger person (like a college student} follows them in. They are introduced as "The Scribe' (makes me think they should be wearing a toga and carrying papyrus!) Anyway their sole function is to record what transpires leaving the doctor free to provide CARE and not be bothered with DOCUMENTATION. Sounds like the old telephone game to me. (The more people involved the more the facts change.) Next time I think I'll ask some questions re education, training, etc. Might prove interesting. Maybe there is a Scribe School somewhere in the Universe!!!LOL. It's funny but not really because I believe what they write has their own take added in. They don't say anything or add comments. They just carry their clipboards and write.!
I'm with all of you on this one! Basic spelling could kill you...Hyper v Hypo = Typo! Or worse. 'DEFINITELY' misspelling is my pet hate. I'm a teacher (of Art not English thankfully) and I despair at the lack of the basics. These scribes may be students but surely they should at the very least, be able to manage correct grammar.
I’m afraid this is only too common. Well done for getting it in writing though. I would recommend a strong complaint about their knowledge and understanding of thyroid complaints. I am beginning to think that we should carry such letters to fire off to anyone and everyone that talks rubbish.
I don't know how it works for GPs, but specialist clinicians notes (the typed ones sent back to your GP with a copy to you) are dictated by the doctor and typed by a typist. Unfortunately, not all doctors are clear in their dictations - and also unfortunately some typists aren't switched on enough to not just type what they hear when it might not make clinical sense. Of course, the doctors should be checking these letters before they go out, but they don't always.
I was in the surgery when the GP dictated the referral letter - he did it over the phone to the secretary. All that he dictated was in the "free text" box where he put why he was referring me - three sentences basically "This XX year old lady with....... etc..... ". All the other information was from my records so maybe a computer button pushing exercise to lift the information onto the form. I don't know if all "referral letters" are done this way now, certainly before they were proper letters not a template form.
You're right on the money. My sister is a Medical Transcriptionist. Been doing it for years and works from home. She says most doctors really don't know how to dictate in a clear and concise way. And some aren't even adept at using equipment correctly so words/phrases are not always clear or captured. Add a foreign accent and you have a recipe for unclear dictation. Then add a transcriptionist who just types in what she/he thinks they heard instead of leaving it blank to be filled in by the doctor when he 'supposedly'corrects it and there you are!
Yep, I'm one too and about a week after starting the job it soon became clear why my medical letters always had errors about clinical information in them. The worst is when they clip a bit of the audio off at the start and you have to infer what they mean (e.g. "{clipped} happy with the result of the procedure" - who is? The patient, you or someone else? The subject of the sentence is so important!). It's actually part of data protection to make clear, concise and accurate notes, so they're breaching those rules in that sense.
They don't always know medical words, either. Some of them don't know the names of drugs, pronounce them strangely or spell them out incorrectly (mostly surgeons, but I've seen it in medical specialties when using the name of a drug that's not within their specialties' usual remit). I've seen some made up medical words too that are almost right but not quite!
I've worked for NHS and private. Both have issues but I've found NHS to be infinitely worse.
I imagine if you were an excellent typist who really knew the keyboard without having to see it you might be very good at your job. I have seen people use a computer without looking at the keyboard. They are amazing. Wouldn't work for me, though, I would never get anything typed if I couldn't see the letters while I 'hunt and peck.'
One of my GPs wrote 'had a chat' but clearly had left more detailed notes where I couldn't get to them. Another GP in the practice knew all about the content of the 'chat'.
Oh good grief! I don't think anyone takes a pride in their work any more, how on earth can you mix up patients like that? I wonder if anything was put on other person records that has nothing to do with them.
Sometimes stuff doesn't get recorded or passed on at all!
In 2001 I broke my ankle and fibula which was screwed and plated. On admission I told them who my doctor was and the surgery address. When I was discharged with an airboot on (a new thing for the NHS!) and crutches my in-laws insisted I stay with them because hubby was working abroad and they lived in a bungalow and would kindly look after me. It was arranged for me to visit a local NHS out-patient clinic for physiotherapy and follow-ups continued at the fracture clinic at Southampton General. I had no need to go to my GP for medication etc..
Fast forward to around 2013 and I visited my GP for something and mentioned in passing about my fracture. ..."What broken leg and ankle?" said the doctor. The hospital never passed on to my surgery that I had been operated on and had a selection of titanium and surgical steel inside me!
All of this worries me. What happens if you are admitted to hospital unconscious or in some other state and with nobody around who knows your medical or medicinal needs. If they look at your patient records they might give you something that might cause you serious harm because the record is wrong. Imagine that!
I haven't gone as far as wearing a medic-alert bracelet but I do carry a card in my wallet with next-of-kin/contact numbers and stating that I'm on levothyroxine and the dose.
I wouldn't trust that someone would check your wallet that thoroughly-except to find your insurance card!. I've seriously considering having "Pacemaker" tattooed over my scar! I figure the first thing that happens in an emergency is they stick EKG leads all over you. The caregivers would have to be really out of touch to miss it.
ShinyB, I wear an SOS Talisman pendant with a paper insert on which I've written (using my strongest reading glasses and thinnest nib pen) the basics of my medical conditions, with meds and dosages, known allergies etc. I've also put in warnings: T3 only!!!! In single dose!! Do not give thyroxine under any circumstances!!!! Only without quite that many exclamation marks.
I need to get a new insert because the current one is crusted with Tippex, but it's a comfort to know I have this as a back-up. My medical records are an absolute mess. I've tried to have them corrected, to no avail, so the pendant is my insurance against mistakes.
Good idea. Another thing i do is carry a large index card in my purse with a lot of good info clearly and largely written. The index card is 5 x 7 and I keep it sealed in a small freezer-quality ziploc baggie to keep it dry. I also update it religiously. If anyone is looking thru my purse to find emergency information they will (hopefully) find this bag first. At the top on both sides "emergency Info" is clearly printed in big red letters. (I believe in colors. Writing pops out more.) If anyone misses this card they are in the wrong purse. And I keep my purse and wallet uncluttered. Just another item for my OCD arsenal!!!
Hypercat and apnoea still working their mischief through the night. 😒 Although, I've just slept with my eyes open through a subtitled Danish drama thingy...honestly no idea. Nighty night.
Isn't that the normal reaction to anything with subtitles?!
We finally made the decision to shut Madam Purrkins downstairs, in the slighty cold back porch which is a bit chilly. She was spoilt by a little electric cat blanket though! She'd taken to howling around upstairs at 5 a.m. which was not going down well lol.
I've just seen your comment after responding to Spongecat above. You're quite right, and despite a recent forum discussion I'd already forgotten about this. Perhaps it's time to have another go at correcting my record.
Maybe ,but there is a similar provision in the current Regs. yet a practice convinced a court that a patients record should remain unaltered in 2013. the new regs are supposed to give data subjects more rights but there are bound to be legal exceptions.
Hi Lulu. One positive I noted is that your GP now gives you access to your record. I have had online access (here in US) to all my records via something called the 'patient portal system'. Sometimes, info is incorrect but at least I have the option of asking that doc to correct it. I believe this is fairly common here. But it is something that should be available to all patients no matter where we live. It is something we should all push for. I recently saw a dr while hospitalized who wrote under family hx my mother died from some metastatic brain tumor. She actually died in a car accident. It had no bearing on my care but it was very annoying to realize that I had not been listened to and made me wonder what else they might have gotten wrong. Scary!
I recall reading in a patient medical advice book the recommendation you send your doctor a letter for the purpose of your visit. It said to time the letter's arrival three days in advance. Even if the doctor just glanced at it before they entered the room to see you, you would be reinforcing the information for the second time. Maybe more of the vital information sinks in this way. If your doctor seems particularly dense maybe add a follow up letter (like post job interview), three times a charm ...
That's brilliant. A wonderful medical variation on the adage. "Tell 'em what you're going to tell 'em; Tell 'em what you want to tell 'em; then tell 'em what you've told 'em." If the docs haven't got it by then they need to move on.
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