Following a mistake by a doctor at an outpatients clinic, I asked for my records which came through quickly. There was absolutely no record of the appointment where the mistake occured. I saw the same doctor yesterday at an outpatients clinic, and she told me she had been asked to sign that I could have the records. She also asked why I wanted them.
We both knew she had messed up but there is no record. I wanted to tell her that she had no right to ask why I wanted them (I just said I keep records of everything) but I cannot find any information to say I am right in that she should not ask. I can then take it further with the hospital.
Any clues where I may find this information? Thanks.
Written by
serenfach
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It may just have been an innocent comment and when it's one word against another which can't be proved it's really not going anywhere.
As for hospital notes, they aren't a word for word record. I have a months worth of records following the death of my husband in hospital, things are entered that weren't done or said and things that were said or done aren't entered, we have a formal investigation going on but it's honestly a waste of energy, I cannot fault the complaints team as they are doing all they can but with inconsistencies on the records it's impossible to make progress.
No, unless you are seeking access to medical records with a view to commencing legal proceedings (pursuant to the Clinical Negligence Pre-action Protocol).
She was pretty persistent in her questions, I think to gauge how much trouble she was in. She gave me an injection (the right one) so that should have been documented, but it was like I was never there!
Thanks for the link SeasideSusie , I just wanted to let the hospital know it was not appropriate. but need something I can point at, if you see what I mean.Unfortunately I will have to see her again regularly, as she is the only one who does the treatment within a 70 mile radius. She is one of those who "knows best what is best for you" type.
I don’t think there a legal rule or policy which prevents them from asking, but there’s no obligation for you to give a reason. I would have also said “For my records”. Had you said I want evidence of the error you made… the hospital would have still had to provide records but you might have been drawn into a wider confrontation.
I had my records sent recently. Most of 20 years worth… the most recent tests were not included. They have to be marked “filed” or complete by doctor, after the outcome has been discussed with you. It might not have been processed & finished yet. Was the appointment recent the record might not be available yet?
That may also explain why they sought her signature to say you could have the records? Ive not heard of that being a standard requirement. I have records from many departments, I very much doubt doctors in every case has
To give signed permission. Perhaps she didn’t sign, which is why you don’t have the records.
It’s true that there are often many inaccuracies and information omitted, Sometimes its administrative eg doctors has obviously dictated for letter of how my daughter was accompanied with “parents” but instead typist has put “Terrence” Or they’d included an odd reference about work or family but not pertinent medical information discussed at appointment.
She did not know I had already seen the records, but the appointment I had a few weeks after the mistake, was recorded.
A letter sent by the hospital informing my GP I had been seen on that date was also missing, although I have seen the letter as they also sent me a copy!
My only hope is that she is now worried about it, and will act professionally from now. Stop laughing!
I can understand them asking, I have seen my medical records but for psyc (CMHT) so these were all paper records - I had to go in a read through them!!
Nowadays most records are put online but diff teams may be separate so this could explain why some were missed. So this letter to the GP - this is on the GP records and is it held separately?
Also you don't need proof to take up the mistake - if they made a mistake did they correct it? What danger level was the mistake? People are still human and mistakes can happen but has it been resolved or are you looking for proof? If it happened then you don't need paper proof you can take it further or if has been dealt with move on
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