can my mum see her hospital notes whilst on the ward?

[hospitalstay]

My mum is in hospital and wanted to see her ward notes for example to see what pain killers she is on and how her leg injuries (which occurred since arrival on the ward) had been logged. She has been told she is not allowed to look until after she is discharged via a 40 day turnaround request. Does anyone know if this is correct? Surely there should be paperwork she can sign to enable her to look whilst on the ward if she is certified as of sound mind (which she certainly is). Thanks

Maybe they worried about possible complaints and need to have lawyers involved before notes are released?

Sorry just saw hopefully injuries have been logged not how they happened.
Does she think they're not being recorded accurately?

I don't understand the painkiller bit, surely she would just ask the nurse giving her any medication ? Does she think they won't tell her the truth ?
Does she know how she injured her legs ? Does she think they will have documented the cause as something else and why ?

We understand that it is not her full medical notes. She wanted to see whether they had logged her leg injury as an accident they had caused or not and also if pain killers were only added after leg injury. They are not prepared to tell us anything which obviously is making her very suspicious. Notes are not all computerized - results of scans etc are but plenty of notes have been hand written. Anyone working in a hospital know if you have right to request seeing these notes whilst still in hospital?

… but true

Those asking if she is confused about injury - no she is not but she wants to know what has been logged.

If her leg was injured while on the ward am incident form should have been completed. They should be able to tell you if this is the case. I would have thought someone - either a doctor or nurse in charge should be able to answer your questions. You can contact PALS while your mum is an inpatient if you feel your questions haven’t been properly answered.

Thank you for this. Are you saying an incident form should be completed regardless of whether they say mum caused the injury herself or someone within the hospital caused it? Just the fact that she needed to have an xray for an injury that occurred after admission to the ward should result in an incident form? What should she do if there is no incident form? Does an incident form get referred anywhere or what exactly is it? Would this explain why they are so reluctant to speak to her then?

I had a look through mine when I went for an mri recently. No one said not to.

Went through my maternity ones too when I turned up to appointments.

Any incident of someone being injured (patient, staff, visitor) would usually have an incident form, sometimes called a datix. What happens after that would likely depend on how serious the injury. Obviously minor slips and trips happen from time to time and wouldn’t need much analysis but something like a fracture might need more investigation. But they really should talk it all through with your mum.

thanks - so what would you do if they are not talking it through? If you work in hospital does she have the right to request to view her notes whilst still on the ward or not until she is discharged?

It’s been a few years since I worked in hospitals but I would think if you are not satisfied you should speak to PALS (Patient Advice and Liaison Service).

It’s definitely not been my experience in the U.S. i can’t believe people go along with this.

I’ve caught critical errors by reviewing my notes and labs in real time. I don’t mean recording errors, I mean errors that could have seriously impacted my health long term.

I haven’t been so angry reading a thread in a very long time.

I agree with @MoonriseKingdom it's time to get PALS involved to advocate for your mum

Let's give an example of why hospitals can't just hand over the full notes. A hospital I worked in received a request from a young adult for their notes from childhood. I got the usual request to check the notes for third party information. In the nursing notes it recorded the mother revealing to the nurse that she herself had been raped, and asking for help. Clearly that information had to be redacted before releasing a copy of the notes, as it would be horrific if we accidentally broke the confidentiality of the patient's mother. It's not as easy as just handing everything over and hoping it's all fine.

I sneaked a look the last time I was in. They had my next of kin as an old boyfriend (I’ve been with DH for 20 years!) and my address as one I lived at whilst a student 30 years ago 🤪

Agree. I didn’t realise you weren’t ‘supposed to’ either?

I took a photo on my phone of my birth notes on the postnatal ward! They were about me so my information, I would have found it bizarre to be told otherwise.

You would be even angrier to know there were no ambulances to attend so we carried her to car and took her to a&e but the delay has affected the prognosis.

Majority accept anything here in England. No idea what our government will have to do before people protest about their behaviour, hard to imagine they can behave much worse. Look at the acceptance of Matt Hancock. Marches I have been on are so poorly attended it is unbelievable despite knowing people are dying due to lack of appointments with doctors and delays getting to hospital or waiting times in a&e. Newspapers report elderly people lying in rain all day under a groundsheet waiting for ambulance yet there is total apathy.

A&E affects everyone of us unlike other areas of medicine where some use private healthcare so everyone should be very concerned as anyone could have car accident and need an ambulance. The level of delays is causing deaths and worse outcomes. If my mother was heavier we could not have carried her.

I dont understand why the mothers nursing notes were in the childs records. They should be clearly separate for this very reason.

However this situation is very different as she is just wanting to see a folder of information that was only created 3 weeks ago when she was admitted to the hospital so would just show a&e admission and then the time on the ward plus presumably any meds given in that time. Nothing should be a surprise for a patient who is of sound mind and quite possibly they could pick up important errors such as next of kin or dose of medicines that they were taking prior to admission or allergies etc. There is no reason for her to be banned from seeing it especially if she has been injured and needing xray whilst on the ward.

People really are so ignorant and entitled. It goes hand in hand these days. The nurses are right and have a legal obligation to keep your notes private. They are nursing and medical notes that belong to the hospital not you. That's why you have to request them via the freedom of information act, despite your opinion that because the notes contain information ABOUT you, you should have free reign to read them at your demand, they are in fact legal documents and have their own bureaucratic process to follow.

In the us, I now get a copy of all the notes generated during my visit within minutes of leaving a doctor’s office. It happens automatically. I get a copy of almost every lab result automatically. There are a few tests that might be harder to understand or are sensitive that they delay for a few days by policy to give the doctor a chance to contact the patient first and provide the results, but if the doctor fails to do so, the results transmit anyway. I don’t know if there are any test results that don’t auto transmit if the doctor fails to do a timely review, but I suppose it’s possible there are some.

it’s the general attitude that the patient is not in charge of their own care and should just be passive that is so bizarre.

Removing of the notes is to preserve ur family members confidentiality. Even if ur family member verbally tells you information it still does not give u consent to look at her notes. I do have to in most trusts apply to see your notes and I believe some trusts charge a small charge from what I have heard.
Your mum however should at all times have an informed choice as to what care she is receiving, and why and can question to anyone nurses or doctors why what when she is receiving for what certain drugs, investigations etc. this should always be shared with ur mum especially in order for her to give informed consent. She shouldn't have to look at her notes to find information out regarding her care. Please speak to the nurse in charge on the ward. He is she will explain on more detail. If you are still
Not happy there will be a patients charter within ur trust that u can turn to for more advice.

That's strange it's usually hanging on the bed frame. They come in periodically to fill it in. I would be worried.

Seriously, get a life. The staff were not sitting around on their phones when they were saving my dads life. Or my sisters. Judgmental af

She has the right to start the request to view notes whilst on the ward but the process can take up to 40 days so she is likely to be discharged prior to viewing them. It does all sound strange that her leg injury is not being discussed though, if you contact the hospital's PALS department and outline your concerns regarding this and use the phrase 'the hospital has a duty of candour' to verbally inform my mother of the information she is requesting regarding her leg injury. In terms of the painkillers, she should be able to ask the nurses what date/time the prescription for those started, to work out if it happened before or after the injury.

Hope you get somewhere soon x