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

Actually this is exactly what worries me about the medical profession

You are writing about the patient for the benefit of the patient. Why on earth would you think they belong to you and not to patient?

I'm actually in complete agreement with open access too. However where I work it is against policy and therefore not something I'm going to openly allow.

Patients' behaviours are relevant to their care in the speciality I work in. Not to mention we have the right to work without abuse. Patients who end up assaulting staff don't do so put of the blue they are almost always known to exhibit these behaviours and where it gets recorded is the medical notes. This patient ended up with a warning within a week or 2 of his treatment of a cleaner and then a "contract of behaviour" after that for spitting at the woman who tried to take his lunch order and told him there weren't any beans on the menu. I'm not sure if he continued along that path and glt himself banned from the trust because he was transferred 🤔 Nobody has the right to come into a hospital and abuse staff, sorry if you don't like that.

@MardyHa most patients SHOULD know what meds they take. Unless its a new med and surely you would be told why you have been started on the NEW meds in the first place!
What your saying doesn't really correlate as to why patients want to have their files. Do patients have full understanding of the NEW medication?

It's all well and good reading medical terms but do you actually understand what is what? Surely you would just ask the nurse about your meds.... INFACT a pharmacy tech usually goes through certain things like warfrin you would have counselling your not just given new meds and sent home...

Patients who have repeat prescriptions woth lists of their medications on don't bring them to hospital when they've ran out and want an emergency supply. Patients who have been sent clinic letters detailing exactly where their cancer is, what chemotherapy they are on don't bring that to (a different) hospital when they have complications they want seen to, patients who have deathly allergies to medications and have this written in places they have access to like the above, do not bring them to hospital. In my 15 years of experience as a HCP the general public cannot be trusted with their own medical notes.

I think the best solution is records to be kept in hospitals with easy and free access between patients, treating teams, and GPs. Patients should also feel encouraged to ask questions about what is written woth regards to their treatments. That second part is generally the culture in my workplace but I understand it isn't like that in a lot of places.

What misinformation could possibly reach a patient by a patient seeing their own records? Unless staff are recording misinformation, there is no false information to transmit.

I suspect what you are really implying is that patients are too stupid to be involved in their own medical care and that you don’t want to take the time to answer questions from patients who want to be informed.

Yes that’s all great in a world where there are medical staff with time to talk to you or your parents / dependants. But when your father is prescribed a drug he’s allergic to and then they’re about to give the dose, it’s lucky that I checked the notes at the end of his bed and raised the issue. That’s just one example of those that have happened to people close to me. Others include unwell parents who can’t speak for themselves and a friend who nearly died due to incorrect treatment, referenced in her notes. Sadly later on, pages of those went missing inexplicably. That might have accounted for her taking it upon herself to help her mother read her notes while in hospital, maybe she should have followed the rules and not raised the fact he’d been prescribed blood thinners while having symptoms of internal bleeding. Be a good girl?

None of the reasons I’ve seen make me think notes shouldn’t be available to patients, when thinking of it from the patient’s perspective, that is. There are far more reasons for, than against. From the patient’s perspective.

There are better ways to handle these things, which don't smack of proprietorialism and distrust. What I do see, though, is that kind of change would take more energy than the nhs can spare right now , when things are so difficult.

This. And so often the reasons given show lack of critical thinking from people purporting to be healthcare professionals. Which makes me want notes to be available even more. There’s also an institutionalised element of ‘this is the way we’ve always done it’ which is concerning.

@MardyHa there's a lot of shouting down and "I know it all" tone on here. Paper drug charts are being phased out and have been for some years now.

Perhaps in some trusts the paper drug chart is left at the end of the bed like your saying

There's a reason why Doctors study for years. I'm sorry but a lot of people do not have the same amount of knowledge as a doctor.

You will be able to read but you most definitely won't understand the medical terminology so either way you would NEED to speak to a nurse or a doctor REGARDLESS.

Begs the question as to whether notes should be written in such a way that they are unintelligible to the person they are written about🤔🤔🤔

In open access trials they found doctors were more thoughtful on how much medical jargon was necessary. They also found that patients were more empowered to ask doctors about the bits they didn't understand, even when they might previously not have asked.

There's a respectful dialogue to be had that understands that patients should have the right to understand the contents of their medical records (even if they don't have a medical degree) and medical professionals have a responsibility to facilitate that.

Also somewhat arrogant to assume that with the assistance of Google your average patient can work a hell of a lot out. The Internet has somewhat democratised medical jargon

@Icedlatteplease I knew someone would come along and start being arsey about medical terms.

Nurses usually work in one speciality and you are familiar with that. I recently well nearly 2 years later have moved to a different department and today I asked someone what an abbreviation of a word meant because I had no bloody clue, I still find it daunting to where worked previously for 8 years.

I was not suggesting that relatives as fickle by any means 🙄🙄

She should have access to her nursing notes. And drug chart. But not her medical notes.

No, me neither. And I'm more than happy to go through the drug chart with parents (in my case)

But the notes is information about the patient. Therefore it's the patient's information? Why should the hospital withhold the patients own info?
Puzzling

How utterly patronising to think that people wouldn't be able to understand their own notes. Some people won't be able to understand. Others will understand everything (and not necessarily because they are medical trained either).

I'm often having to explain my daughter's condition to junior doctors, or those from different specialities. They don't necessarily know the terminology, and yet they'd be allowed to look at the notes. No criticism from me for them not knowing the minutiae of every specialism, but when it comes to the health of themselves or their young children, people are often pretty confident with lingo that relates to them.

Regardless though. They could be in a foreign language, and the patient should still have the right to look, because it is their days, whether they understand it or not.

Don't the nurses write on the medical notes? A lot of these notes are on an electronic system now.

What are nursing notes? 😳

@Somuchgoo if you know so much why are you not a doctor yourself?

@Ivyblu, no, not always. We write on separate paper in the nursing notes. Our obs and assessments are on iPods, and old medical notes are on line. But current notes are in the notes trolly. From doing agency, I've learned that all trusts have different procedures. Some are still completely paper based.

I think I remember the paper notes but when Dr's Clark patients it's in the medical notes and nurses too write in that same file!

Agree some many things vary from trust to trust though.

In my over 15 years of life experience with medical professionals, I have encountered:

Doctors that cannot access test results from a different hospital that I had to provide (I keep all documentation on the cloud). Doctors that cannot access letters to and from their own department. Test results, referrals etc that mysteriously disappear. Systems that don't even record the names and locations of all the doctors who have treated a patient.

A doctor that mansplained to me how I shouldnt be worried about something because it was known to be benign. I then provided a copy of the letter (from my cloud storage) from the specialist from the national Centre of excellence that advised the contrary and that had previously been emailed to the first doctors department.

A doctor that prescribed me a penicillin derivative when I had penicillin allergy clearly marked on my records. When i queried the similarity in the name he told me "Im the doctor. This isn't penicillin, there's no contraindication and penicillin allergy is overdiagnosed" (which in hindsight should have been a clue). Thankfully my allergy is slow acting else he could have killed me.

Based on the logic of the quoted post, HCP simply cannot be trusted with medical records!!!😁😁😁😁

But I do agree a joined up open access system is the right solution. Love the more transparent attitude compared to some posters

I think that you should request the information politely from the nurse in charge of the ward. If they decline to answer, ask via PALS. Whilst many people do a great job, this doesn't mean that mistakes are not made nor does it mean everyone will be upfront and honest.

Only nursing notes will be bedside. The nurse looking after your mum that day would have written in the nursing notes about what happened to her leg.

If I were your mum I would ask for the curtains to be closed for a sleep or wash and then go through and photograph the needed notes.

This, a thousand times over.

Sorry just seen that they have taken your mothers notes away and no one else's. That would make me suspicious. Ex nurse here.

Crikey someone's spikey and defensive 😂

No I don't want to become a doctor just because I understand your super secret language 🙄

There's nothing wrong with being in a new specialty and not knowing the acronyms, or a general paeds registrar who doesn't know the detail is a very specialist area. That's why specialists exist.But patients and parents often become experts in a very tiny area.

There are people in here who have saved lives by looking in their notes. Clearly they didn't find then incomprehensible. And if they did, that's still no reason to bar assess.