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General health

why would the GP not have a record of my condition?

13 replies

AshleyWilkes · 04/11/2015 16:01

Diagnosed with polycystic ovaries 7 years ago. Previous doctor fully aware of it and worked with me, gave us both advice while we were TTC.
We moved to a different area last year. Registered with new GP straight away.

So I went for the dreaded smear test today. Sat with the nurse and she asked me questions, the usual stuff.
When she asked me how long ago I had a period, I replied it was approx 6 weeks ago.

"Oh so you're overdue?"
I replied well yes I have polycystic ovarian syndrome and my periods have always been all over the place.

She seemed surprised and I commented that I assumed it would be on my notes.
From the look she gave me you would have thought I'd suggested she jump naked out the window.

"Oh no dear, it's not on your notes."

WTH??!Confused
Am I right to feel slightly bemused? Left the surgery feeling a bit confused.

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SisterMoonshine · 04/11/2015 16:06

If it wasn't for the: "Oh no dear, it's not on your notes"
I was wondering if you'd just maybe caught her out that she hadn't looked at your notes.
Odd

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ItsAllGoingToBeFine · 04/11/2015 16:07

Do nurses have full access to a patients notes? I thought they just did the job they were asked to, and didn't refer to notes?

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LineyReborn · 04/11/2015 16:08

She means, Oh dear you're not expecting me to have read your notes?

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LineyReborn · 04/11/2015 16:09

In my practice my notes come up on the computer screen for both doctors and nurses.

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Enjolrass · 04/11/2015 16:09

I mentions my pcos to my nurse when I had my smear a few weeks ago.

She then read my notes. As far as she was aware I was there for a smear and that was it.

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Sidge · 04/11/2015 16:22

Do nurses have full access to a patients notes? I thought they just did the job they were asked to, and didn't refer to notes?

Nurses aren't doctor's handmaidens you know, they are actually independent practitioners, especially in primary care.

We assess, diagnose, treat and review patients regularly often without even seeing a doctor

OP - It depends how your notes have been coded on the computer system - often previous medical history can be scanned but not yet summarised, or just the current active problems that are requiring ongoing treatment or medication (such as asthma, heart disease, kidney disease, etc) so wouldn't show up on the 'front screen' or list of current active medical problems.

If I have someone booked in for a smear I'll look at their current meds, any diagnosis or active problems but I wouldn't go in and read all their notes.

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hollinhurst84 · 04/11/2015 16:38

Well my notes say I'm asthmatic. I'm not. And they keep saying it's been put in past problems but every time they ask "how's your asthma?"
So I can see how something could be missed off!

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AshleyWilkes · 04/11/2015 16:38

Sidge
Thanks for the clarification from your perspective.

I'm seeing my gp next week for something else so will mention it then.

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ItsAllGoingToBeFine · 04/11/2015 17:12

Nurses aren't doctor's handmaidens you know, they are actually independent practitioners, especially in primary care.

I'm really sorry, I didn't mean it to come across like that Blush Its just that in my practice you go to a treatment room for minor stuff like ear syringing/stitch removal etc. The nurse has a note on her computer that says name and something brief like "stitch removal" You have to tell her where stitches are, which ear etc

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Sidge · 04/11/2015 18:01

That's pretty standard ItsAll - the appointment systems often have a small box for the receptionist to put the reason for the appointment in but the nurse should always clarify what the patient is actually there for (you'd be amazed at how often it's not what's in the box!). I usually have a quick look at the front page and meds and any alerts but don't have time to look through all the notes.

Sorry if I was a bit snippy, I get very tired of the presumption that nurses just do as they're told when we actually have a lot of skills, experience and knowledge. I got asked recently "do you have to do any training for this job" Hmm Grin

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DownstairsMixUp · 04/11/2015 18:06

I moved nearly five years ago from my home town to where I am now and loads of my stuff was not in my notes from my old GP. Hmm not sure how it still happens!

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iamaboveandBeyond · 04/11/2015 19:12

My nurse def had access to my records when i went for my smear yesterday (see my thread about it, lol) but i told her i had a bastard mirena in and she didnt know. I think its just standard that they dont read your lifes history beforehand, nothing to worry about :)

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Pleasemrstweedie · 04/11/2015 21:09

My allergies were not in the summary, which meant I couldn't get antibiotics when I needed them. Nurse practitioner said it would take her too long to try to find an original letter in my notes, noting that I had 'a lot of notes', and told me to go to A & E if I started getting red lines up my leg!

I don't reckon the summaries are very good. I bet they miss all sorts of stuff out.

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