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I think GP, or someone, has changed some stuff in my medical record(20 Posts)
I had some blood tests done last year. Results came back showing I was slightly anaemic, in fact I posted about it on MN at the time asking for advice. Since then I have been diagnosed with a condition that is notoriously hard to diagnose and it turns out that anaemia can be a red flag for it, but hindsight is a wonderful thing so no big deal from my perspective. Yesterday as preperation for a meeting with a consultant I looked at my online medical record to make a note of various test results. Last years results no longer show I was anaemic, they are now in low normal range. The date of the test has changed too. The date on my medical record no longer matches either my diary or my MN post; my MN post is a week before the date now on the test results So, they have been changed.
My question is, is there any kind of audit trail of who goes into a medical record and when? If I ask the practice to investigate, will there be any evidence of things having been altered? I have already tracked down the lab that does the tests for the practice, and they have changed too. All of which strongly suggests Im confused - but I have the MN post and my diary clearly saying that things no longer match up. I'm not sure how to prove I'm right, and if someonehas changed stuff then I'm pretty damned cross. What do I do?
Could it be that you had preliminary results and then final results?
Every time someone enters something in medical notes or alters something it will create an audit trial .
I think the best person to speak to would be the practice manager.
Were you actually given figures or just told?
Because it's possible you were low, and they said "slightly anaemic" without adding "but just into the normal range".
Sometimes I've been given figures (I was 2.8 when pregnant with dd1, that did give some cause for alarm!) and sometimes been told "oh you're on the low side, we'll give you something to bring you up" which could mean I was in the normal level but low.
It seems unlikely someone would bother to change things which sound very trivial. And why would they bother to change the date too?
Or maybe you had a second test a week later to see if the levels were going up or down. If you'd started treatment that would then add up with being just into the normal range then.
I really, really doubt someone has retrospectively changed your record to cover up that a link wasn't made to a diagnosis when from what you said this wouldn't constitute a failure of care in any case. Nobody in a GP practice has the time or the interest for that kind of eagle eyed obsessiveness. It's much more likely that something mundane has happened, such as that the later date is when the results were actually logged by the GP practice, or the thresholds for "normal" have been adjusted, or somebody cocked up with the data entry. But by all means engage with the practice and ask to have your record checked/for an explanation.
Yes there is an audit trail of any and all access to gp or hospital records.
It might be useful to compare gp and lab records.
How do you know your original result was low? Did you access your records? Receive a letter or printout? Phone call?
I have been given wrong results by receptionist once before. I was so concerned I asked to speak to the practice nurse. She gave me the correct results. I suggested that maybe the clerical staff shouldn't be giving results over the phone when they clearly couldn't understand the lab report.
That's actually something really hard to change on a medical record - the lab results just come as a bundle and you can't alter them or put them in individually.
Your best bet is to contact the Practice Manager - any entries or alterations on your record leave an electronic trace so it would be easy to see what happened. Plus of course they can get the originals from the lab.
Thanks for replies. I know it sounds bonkers. But I know what the results said and I know what they now say. I sent an email at the time to a friend telling her the exact numbers because she suffers from anaemia too and I wanted her input. I also posted on MN. Both of these have an exact time stamp of the results which no longer matches my medical record.
I spoke to someone at the practice today who phoned the lab for me, lab data also says I was never anaemic. But I have looked these results up multiple times over the last year via Patient Access and I know what they used to say. I know the exact figures they were. And so I know they have changed...sometime in the last few months I would suspect. But for the lab ones to be changed too?? I am wary of taking it up with the practice in case it turns nasty...but I feel I can't leave it because if someone has changed them, that's pretty out of order.
If I change practice and then ask for an investigation, the audit trail would still be there?
Why would someone change it , are you in the midst of a complaint about something with the practice ?
@Floralnomad No complaint so doubly odd. But might complain now tho.
Were you ever told they were low, or did you just see it on Patient Access? I wonder if there’s been something wrong with the system, rather than the practice?
There will be an audit trail if someone changed them, but they wouldn’t have been able to change the lab results too. Which seems to suggest that what you were looking at in Patient Access wasn’t your results?
Were you reading the right units/ranges? The lab my GP practice uses often gets the units/ranges wrong for the UK and then posts corrections weeks or months later. Or alternatively your GP initially might not have used NHS criteria to diagnose you but using the latter you might not be anemic at all. The latter is a bitch with tsh tests - privately you can get treated above certain levels, but on the NHS if antibodies and other levels are normal they might allow it to double before treating you!
I have no idea how access logging works on the NHS but its normally coded timestamp and user is via code on the webpage into a database, sometimes as a blog ( large binary file) blogs are impossible to fiddle at the back end plus IT would be totally separate so I would guess auditing would be true to the events.
Thanks @Legoandloldolls I've decided that I will be looking into it so hopefully the audit trail will clarify whether its some weird glitch or deliberate.
GP surgery would not be able to change the lab results in either the lab or your medical notes . The results come to the notes direct from the lab and the GP or anyone in the practice cannot change the actual number. All the GP does is write a comment .
Maybe you were given the wrong results?
Even if the lab subsequently change units it is not applied retrospectively so would not change bloods already filed.
In my area the GP surgery uses the same system as the hospital (Ice). You can see the audit trail when you access records. Even if you accidentally click the wrong name, there is a stamp that shows you accessed the file. Results are uploaded by the lab and the surgery will have read only access. They can order tests, but that is by a different screen. Every test has an alphanumeric code, and the results are logged against the same code. So, for example, the request may get a code of UE3585768DB169, then the results will have the same code.
That’s really odd.
Dd has an unusual condition which is notoriously hard to diagnose and like you being anaemic can be a red flag for it. She had other stuff which also ties in like low vit d and numerous symptoms. Took 6 years for her to be diagnosed.
Sadly I should think such occurrences are fairly common and I can’t imagine anyone bothering to change medical records but it certainly seems like something has happened with yours. Hope you get to the bottom of it.
No one in a GP surgery would be able to change the dates on a test in a hospital lab.
At our surgery the results come through. We are not able to change the dates they are all date stamped. The only thing that might have happened is some results get an addendum and then the date may change but no one in the GP surgery can do that.
The only other thing that may have happened is if someone elses results got filed in your records. Then an error was found and they retracted it. This would be really rare.