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

I’ve lived in 3 countries other than the UK (ME, Europe and Africa) It seems to be a big secret in the UK that you wouldn’t find in other countries.
How can a patient not be told what they are being given? I asked each nurse that gave me meds what they were, I’ve had allergic reactions in the past and I don’t think they’d want anaphylactic shock added to their day.
OP If your mother has sustained an injury in hospital are they trying to hide something? Sounds very worrying.

@hospitalstay Is your mum vulnerable or confused? You said in you OP she is of sound mind. If that's true, then of course medical staff are not going to tell you her private medical business. That's for her to tell you if she wishes. They won't tell you anything without her permission. So, unless your mum says "phone my daughters and tell them I hurt my leg" they wouldn't contact you.

I was given my notes after leaving the hospital when I had my ds. They had kept me in for a week thinking I had sepsis. When I read through my notes it was another name wrote and not mine. Maybe if I had access to them while admitted I could have told them I was not actually "Gemma"

Badnomad - It is not that I want to see her records or know my my mums business (she wants to see) but I can assure you they are telling me continually about all the treatment, results of bloods etc etc when she is not in the same room so why the big secret about the injury. I am updating her. My mum hasnt told them to share bloods etc with me but they are doing so rather than telling her. Presumed that was standard practice with elderly but maybe that shouldnt be happening but it has been continual over 3 weeks!! I have been on the ward every day so nothing to do with phone calls.

This is one of the reasons why the NHS is so cumbersome. Someone upthread said the records belong to the hospital, only because this is how it has been set up. A few years ago, with the NHS Digital upgrading, patient held records were pushed. Patient groups wanted it, patients wanted it. Just think, a world in which you have all your records from your GP and hospital treatment in your own hands. The NHS blocked it. Information is power. Just think how wonderful it would be if we all had all our records in our own hands, and could take them wherever we wanted, to the healthcare provider of our own choice.

I've worked in 3 different countries and haven't experienced anything like the questioning everything and demanding than I have here in the UK.

I don't have any problem bending the rules to let people/their families have a peek at the notes (despite that it is very much not allowed under information governance rules) however I won't do it for anyone who I just know is going to pick at what has been written by someone else. "Why have they written X when Y happened?" How am I supposed to know? I'm more than happy to explain what I am doing, why, how etc. I can't explain the actions or motivations of my colleagues, some of whom would have been in different departments or even hospitals, and my experience in the UK is that people are not able to accept this. Its just not worth the hassle it will cause sometimes, in this country where people seem to think they are customers and deserve customer service.

That said though, if I were you I would get your mum to ask everyone who comes to speak to her if they are a doctor (since you said she can't recognise who is who. People ahould be introducing themselves anyway) and ask them to eother call her daughter or come to have a chat during vitisiting hours because she has some qorried and questions and you need an update that the nuraes arent able to provide. If it doesn't happen the flowing day after she has done this I'd go to visiting hours and be very clear that I wanted to speak to a doctor and wouldn't be leaving until one made themselves available to me. Don't be aggressive or raise your voice (I'd get security to remove you if you did this) but be very direct and calm and stand your ground. It isn't really acceptable that there is never a doctor available however most doctors I know have a poor understanding of where the line of what nurses are and aren't allowed to do/tell families actually is.

Natty13 why do you think looking at notes is not permitted under governance? Are you working in NHS now or is your experience based on outdated knowledge? New legislation has made it clear patients have the right to access. Hospital records office state that any one on a ward has a right to look at their notes but has to have a nurse or doctor with them whilst viewing (which makes sense so they dont alter anything). If patients want an actual copy they can request it and it will be scanned in and emailed to them (rather than the paper copies sent pre covid) however can take 30 days.

Those saying UK patients are most questioning is likely because our NHS staff are so stretched so we all know however hard they try mistakes/oversights will occur and plenty of posters on this thread have given examples of why it is good for patients to view their notes. It is governments fault not the staff so there is no need to be so defensive if you are working in the NHS, however there is if you are part of government especially if health minister or PM!!

Do you have medical power of attorney? If so you can request to meet with the dr yourself, otherwise your mother can request to meet with the dr with you present. I've never had an issue with staff being secretive, but they won't necessarily be available during standard visiting hours without an appointment.

Ward rounds are the other time your mother can ask, generally they are weekdays first thing

I can only assume they believe your mother allows them to keep you updated on that side of things. Incidents are different, in that they don't come under the same permission, as it's not what she came in for initially. What was the injury? Is your mother not able to tell you? Was it witnessed?

Because it’s my body and my care. My parent’s bodies, their care, my children’s bodies, and their care. Because, while there are some amazing medical staff, there are some terrible medical staff. The amazing staff are under too much pressure. Because more than once, substandard care has been life threatening and checking notes has saved my dad’s life. My best friend’s life and her mother’s. Because sometimes the picture of those records says the opposite to what you’re told when you try to find out why that life threatening event occurred.

Because trying to find a doctor or nurse to talk to you is sometimes impossible. Because sometimes the medical care is so bad it’s abusive. Because sometimes you can’t even get a glass of water or pain relief let alone an answer about your care. Because sometimes, the staff are like…. you.

And your government point is ass backwards - we check records because we can’t get good information or trust what we’re told - exactly in the way we can’t trust the government. I don’t break rules for the sake of it. I followed the Covid rules though, to help the NHS. The government didn’t, did they. I’m not the reason the country is falling apart. But I’m not going to sit like a good girl and trust everything is fine while my dad is given a medication that could kill him, while he’s already told the staff he’s allergic to it, while we’ve already told them - and it’s right there on his notes which I check and run around trying desperately to find a nurse. That’s why. HTH.

OP states that her mum wants to see how the leg injury has been logged.

There's reasons why patients can't just access their own notes without following the protocol.

Staff do wrote about patients..... you can imagine the uproar.

Anyone who wonders why nurses are striking just needs to read this thread.

@Natty13 your post is very interesting. There's complete lack of respect here and nursing has changed so much. Patients literally lie down on hospitals beds like they are at home, security often has to be called, the patients think its ok to shout and scream at hospital staff and quite often it does work and they get what they want.

The trouble is the patients think they know more than the staff. I mean there could be safeguarding issues on your own notes I can't understand how anyone thinks the nurse or a doctor would just hand them over! 😅

I think medical staff should be paid more and have better conditions. I’m the opposite to abusive. Even with the staff that were unkind to me, or shouted or sarcastic. With those staff, something about being half naked and vulnerable makes me be extra nice to them, hoping they’ll like me enough to not forget my painkillers etc. But blind trust? No.

RELATIVES* lie on the patients bed sorry!

It is the information governance rules of the trust I work for that you have to go through the formal process to request them. Of course you have the right to read your own notes, like many rights we have in this country you don't have the right to demand them there and then. Best thing to do is find out whatever the policy is in the hospital wherwyour mother is.

With regards to questioning and demanding, I have experience of being a patient and a staff lember in this country long before tory underfunding had us in this situation. Where I am from, for example, people don't go in to a hospital automatically expecting the worst from the people who are there to care for them. I am not defensive in my practice because I have nothing to defend, I'm happy with the care I give and the standards I provide are what I'd want a relative to get. But it does get tiring being asked the same questions over and over in different ways because someone with access to Google is trying to catch you out whether you actually know what you're doing.

As I said, best thing to do is to get your mum to ask a doctor to update either her or yousnd answer her questions about what is going on with her leg. And take it from there if that doesn't happen. It isn't acceptable that she isn't being kept informed.

Totally agree with this.

Are you serious? The average person I see can't even tell you what medications they've taken daily for years, not even what the medicines are for let alone the names.

If a patient lost some of the notes or forgot to bring them all in, and harm came to them because of important information not being available to the team treating them, who would be to blame? I can assure you in Britain the family would be straight on the internet blaming the hospital staff.

Not to mention patients not agreeing with what's written in the notes. I wrote that a patient called me a dirty cunt once and he complained to get it taken out of his notes. When he told his wife this she said "but you did call her that" his response: " I know I did but I don't want it written down for everyone to read". Says it all.

I take on board what you are saying and your experience. However, there is move towards patient held/total access. The UK is behind (again) in this respect. Many papers have been published in the BMJ that patients, given access to their own records and responsibility for their own healthcare, have more trust in HCP's and have better health outcomes.

The records wouldn't necessarily be paper, and there wouldn't only be the patient copy, the patient just has a copy of what is available to HCP's.

But that’s the whole point - the patient doesn’t know that medication they take - they would have access to all the information if it was available to them. That they might lose them?? They would be computerized?! Having said that, I have had paper records have strangely missing pages before when they were on paper - but not lost by the patient themselves.

I think empowered patients are a pain in the neck for the system, patients with information ask annoying questions. The best doctors I’ve had, welcome those questions, even with the challenges and irritations they present.

I also think it’s about liability. Not the patient’s well-being, the hospital’s. And when you nearly die and peskily request your notes it’s helpful when there’s time for the liable party to read through them first, before you have access to them. But in the few incidences I’ve been involved in / have knowledge of, the patient / family did not want to sue, they wanted to know what happened to them and why, they wanted to know it wouldn’t happen to someone else, that it was learned from, and just to hear the words ‘we’re sorry about that’ instead of obfuscation and gaslighting.

@paintitallover funny you should say that I work for the NHS and no way is a patient allowed to sift through their notes including their bed side notes. Those are for current documentation of bowels,BP, skin, diet charting, and med allergies. They belong to the medical team and are their documentation. They are protected for numerous reasons mainly to prevent misinformation from reaching patients, they are also protected from patients tampering with their information. I've had a patient change a dose of opiate medication. Hence why communication with the team is so important and they should be answering any queries. despite the attitude of a lot of patients "it's not their right to see them"

People are employed purely for FOI requests, their entire job is preparing notes for patients who request them AFTER discharge. That's the process and advice to contact PALS for notes requests is ridiculous they will tell you to ask your treating team for information or advise you on the correct procedure.

I'd love to know how calling someone a cunt is actually relevant to what needs to be recorded for their medical care....

Open access to medical records (eg held online viewable online) has shown itself to be liked by both patients and medical professionals where it has been trialled. There was an interesting interview on Radio 4 about this

One of the first thing that was mentioned was how it focused the medical professionals mind on what should actually be in them.

With the exception of genuine safeguarding concerns, you shouldn't be writing anything in the medical records that you wouldn't be happy to say/show your patient and that us directly relevant to their care.

They belong to the medical team and are their documentation.

And are about someone’s body and what is being said about and done to them, when they are nearly naked and the most vulnerable they can be.

They are protected for numerous reasons mainly to prevent misinformation from reaching patients

Why would they contain misinformation? Isn’t it even more important a patient or their guardian might see them in that case? That’s the reason that seeing them has been lifesaving for my family and friends at times.

they are also protected from patients tampering with their information. I've had a patient change a dose of opiate medication

It seems as though there should be a secondary check then, when giving controlled medication?