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AIBU?

Medical records

35 replies

Teenagecrisisagain · 10/12/2015 12:05

I had an appointment with a doctor at the hospital
Notes were written and everything spoken about was recorded in front of me.

I have since requested a full set of my notes and this consultation is missing. Nobody can find it
It was suggested that I did not see a doctor that day and I replied that I did and saw the notes
I ha e other paperwork from my medical records referring to this appt but still Iam being told there is nothing recorded for this day

AIBU to take this further ? Iam very frustrated and need my full set of notes.

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EldonAve · 10/12/2015 12:07

Do they have a record of your appt? Are you marked as Did Not Attend for it?

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Teenagecrisisagain · 10/12/2015 12:09

They keep telling me they only have record of a scan appt that day (which is correct but I also saw a doctor afterwards and that is what they are disputing)

I have the appt letter and other things referring to this consultation so can prove I saw a Dr tbh but my problem is needing the actual notes from that day

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imgoingdowntown · 10/12/2015 12:11

Kick up a MASSIVE stink. Losing notes isn't on

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Teenagecrisisagain · 10/12/2015 12:12

I'm really really frustrated and upset about it
I need my full notes to work through due to PTSD and I cannot get hold of the most important page :(

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Creampastry · 10/12/2015 12:15

Make sure you put everything in writing.

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Teenagecrisisagain · 10/12/2015 12:15

Who can I actually go to though?

No luck from
PALS
Medical records department
Department I was seen in

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Teenagecrisisagain · 10/12/2015 12:16

I have told them today Iam coming in to view my notes as I know exactly where they were in the folder and I want to see for myself

It's exhausting chasing this up I wanted To request them, pay and get on with counselling/therapy and I can't move forward till I get everything I need

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Girlwhowearsglasses · 10/12/2015 12:25

Complain to the Information Commissioner. Threaten to make complain of not recorded by xxx. The Information Commissioner enforces the freedom of information act which says you can have your notes

ico.org.uk/concerns/getting/

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Scarydinosaurs · 10/12/2015 12:26

When you saw the doctor after your scan, did they write their notes in your maternity notes book?

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Teenagecrisisagain · 10/12/2015 12:28

Yes it was recorded in maternity notes

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Teenagecrisisagain · 10/12/2015 12:29

I have received a copy of the whole maternity file minus this one page

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Creampastry · 10/12/2015 12:38

Had you opted out of the Summary Care Record: There is a new Central NHS Computer System called the Summary Care Record (SCR). It is an electronic record which contains information about the medicines you take, allergies you suffer from and any bad reactions to medicines you have had.

Have you submitted a subject access request - legal right, sample letter below:

[Your full address]
[Phone number]
[The date]

[Name and address of the organisation]

Dear Sir or Madam

Subject access request

[Your full name and address and any other details to help identify you and the information you want.]

Please supply the information about me I am entitled to under the Data Protection Act 1998 relating to: [give specific details of the information you want, for example

your personnel file;
emails between ‘A’ and ‘B’ (between 1/6/11 and 1/9/11);
your medical records (between 2006 & 2009) held by Dr ‘C’ at ‘D’ hospital;
CCTV camera situated at (‘E’ location) on 23/5/12 between 11am and 5pm;
copies of statements (between 2006 & 2009) held in account number xxxxx).]

If you need any more information from me, or a fee, please let me know as soon as possible.

It may be helpful for you to know that a request for information under the Data Protection Act 1998 should be responded to within 40 days.

If you do not normally deal with these requests, please pass this letter to your Data Protection Officer. If you need advice on dealing with this request, the Information Commissioner’s Office can assist you and can be contacted on 0303 123 1113 or at ico.org.uk

Yours faithfully
[Signature]

Get a receipt for this letter if you hand deliver it.

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Teenagecrisisagain · 10/12/2015 12:41

I already requested from medical records and paid the fee for everything

It is puzzling and frustrating as I know what was written and who I saw. There are many other parts in notes where the appt is referred to so I do not understand why it is 'missing'
I will write in again and I've insisted on going in to look through my file myself

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Teenagecrisisagain · 10/12/2015 12:42

No I had not opted out of summary care

These were hand written notes secured into maternity file. Everything else was given to me except that

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blueteapot · 10/12/2015 13:27

Did thy dictate a letter to GP? Would a copy of that help?

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Teenagecrisisagain · 10/12/2015 13:29

No it was all recorded by hand in maternity notes. This is the only page missing though

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Scarydinosaurs · 10/12/2015 13:51

Could you ask for the original book?

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Teenagecrisisagain · 10/12/2015 13:54

Originally I asked to view records and then say which pages I needed copies of. This was declined and I was told to pay £50 for copy of all records.
I did this but a page was missing so I contacted the hospital repeatedly and they could not find it/say there was no appt that day other than a scan
I have now asked to see the original folder myself as I know exactly what section the notes were in and it will be very obvious if they've been taken out as it goes in date order and all midwife and Dr consultations were recorded in one section so there will be a gap of its not there

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HackerFucker22 · 10/12/2015 13:57

Does it involve staff negligence at all? Are you concerned someone has tried to cover their tracks?

(I'm basing this assumption on your mention of PTSD and needing therapy)

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Teenagecrisisagain · 10/12/2015 14:03

The hospital made a massive mistake yes but I don't want the notes to complain or anything g like that

What's done is done. It's affected me terribly and I need to work through it all as part of my therapy. I need all the relevant notes to go through and to process what happened.

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Taylia · 10/12/2015 14:07

Had you opted out of the Summary Care Record: There is a new Central NHS Computer System called the Summary Care Record (SCR). It is an electronic record which contains information about the medicines you take, allergies you suffer from and any bad reactions to medicines you have had.

The national SCR system doesn't have any clinical data on it at all, it's only demographics, GP etc. It's been the same way for all of the 7 years I've been using it.

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stairbears · 10/12/2015 14:09

Not the first time I've heard of maternity notes going missing unfortunately...

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Teenagecrisisagain · 10/12/2015 14:12

It's one page. Probably the most important one :(

I know it doesn't change anything having it but I so needed to go through all of this with my counsellor. I needed everything In Front of me and to go through it all and try to process it

The frustration and time spent chasing up this o e page is just causing stress and a delay in my therapy

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Threesquids · 10/12/2015 14:13

I had eclamptic fits in a very well known London hospital which was solely down to them not monitoring my during a very long and complicated labour.

My WHOLE notes were never seen again after this date!

Since then and with my two other children, I have photocopied and asked for photocopies of everything.

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Teenagecrisisagain · 10/12/2015 14:15

That's awful threesquids

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