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AIBU?

Share your dilemmas and get honest opinions from other Mumsnetters.

I'm cross/upset about my daughter's medical record.

39 replies

ElaineReese · 24/01/2012 18:04

So - went with dd to get her some jabs just now, and I had to sit on the couch as there was only one chair - so when the nurse scrolled through dd's records to check what she'd had and when, I saw clearly an entry from 1997/98.

I had collected her from nursery that day and they'd said she'd been 'off' all day, and she was unusually... well... mimsy and cry-y and not herself. Felt hot to me, but perhaps not. I probably was being a bit PFB, in retrospect.

Being a young mum and anxious not to get it wrong, and on the say-so of nursery, and in the context of all the meningitits hype at the time, I rang the surgery that afternoon and they unwillingly gave me an appointment. I remember little about it other than the doctor being rather patronizing and off-hand, and leaving feeling very stupid. never mind all that 'no good doctor would think less of you for getting the baby checked out if you're at all worried' - oh no. Felt properly scorned and dim.

So today I suddenly catch sight of 'infant had been at nursery all day. Infant appeared pink and healthy. Mum would not be reassured and was surly and irritable'.

I suppose I should write it off, it's a long time ago. But presumably every time I've taken her in for anything from chicken pox to verrucas since, the gp has read that before they see us. Which is upsetting, rather. Also I think that the HVs and nurses who saw us when she was small wouold have said I was a good mother, and not a stupid anxious surly unpleasant woman. So it seems unfair that this has gone down as the True Fact.

Also 'surly' is a thing you can be to teachers, or your parents - for a doctor to use that word, to me, implies completely the wrong sort of relationship with patients.

Could I, should I, do anything? And, of course, AIBU?

OP posts:
ElaineReese · 24/01/2012 19:07

'denies excessive drinking' - ha - bit like 'when did you stop beating your wife?' isn't it?

OP posts:
HoleyGhost · 24/01/2012 19:16

Yep, at one of my DD's early appointments, they wrote down that I was an anxious mother. I had taken her to the appointment on my HV's say so, and told them this, and that I thought the appointment unnecessary. I think that I've always been treated as an overly-anxious mother since. You can't win. Either you should have brought a baby sooner, somehow realising that the umpteenth bug this year requires treatment. Or you are wasting the clever doctor's time, because with their wider experience, they don't see the cause for concern.

MilitaryWag, that deserves a formal complaint. What a prick.

chocolateorangeyum · 24/01/2012 19:16

I work with medical notes all day and I rarely see anything that blunt. Sounds to me like the doctor was surly and irritable.

It was not very professional but has no reflection on you. However in their defence doctors do see a lot of very anxious parents who are difficult to convince and I think he may just have snapped at the end of his tether. He may also have just had the most difficult rude horrible patient in before you (there are quite a few of them about). Also as somebody said before very few people are going to look at your notes that far back.

catsareevil · 24/01/2012 19:17

Writing that someone has denied something in that context is normal, and should not be viewed perjoratively by anyone reading the notes.

For the OP, there is no way that every HCP you see now would be reading entries going back 13 years. It may also reflect the style of that GP, rather than you, IYSWIM.

OldMumsy · 24/01/2012 19:19

I spotted the word shouted on my medical records! I think I did, as I was completely exasperated with a nurse who insisted I should be on permanent medication for high blood pressure. Of course my BP rises to 130/80ish at the doctors because I am in a conflict situation.

I monitor my BP at home regularly and it ranges from 110/70 to 121/83, my BMI is 22 and I get plenty of exercise. I do not intend to be blanket medicated with BP meds or statins just because I am over 50.

sallysparrow157 · 24/01/2012 19:21

But surely 'denies excessive drinking' is factually accurate? He has has asked if you drink a lot, you have said no. The doctor doesn't know for a fact that anything anyone tells them is true, all they can document is what they are told. It's a completely normaly way of documenting things in medical notes - it makes it clear that the doctor has asked the question and the patient has said no, in 3 words.
As for the 'surly and irritable' comment, it may be that the GP was safety netting for post natal depression/a young mum struggling to cope - if you actually were irritable and miserable in a string of appointments it might suggest you were struggling with something and if it was documented each time they would be more likely to realise and do something to help. Of course it may be that the GP was a git!

learningtofly · 24/01/2012 19:26

I do sympathise its not nice to be judged on record particularly if you feel it is misrepresentative. This entry was a long time ago (in medical terms) - fortunately now there are stricter guidelines on what medical professionals enter into a patient record. Entries should be objective and based on fact not personal opinion.

Years ago it wasn't uncommon to read "presents as a jolly fat man" or "normal for area". My grandfathers notes had a line saying "family very demanding" although that was probably very true!

ElaineReese · 24/01/2012 19:29

But the HCP I saw todaywas reading them, there, then, in front of me!

OP posts:
dandelionss · 24/01/2012 19:33

Don't you have a right to read your medical notes ? I would have thought that would be enough to stop them writing anything too 'subjective'

TheLightPassenger · 24/01/2012 19:35

Re:"denies excessive drinking". Agree with cats that "denies" is absolutely standard doctors' letter speak. It could be "denies" pigeon fancying or "denies" pain in her her right arm. It's not implying the patient is a liar. (work in the NHS, non-clinical role).

wrt to the OP - not very nice to described as surly and irritable, and doctor shouldn't have recorded that in the notes, but I agree it's not important enough to go to the trouble of asking for the records to be changed.

learningtofly · 24/01/2012 19:38

You can apply to read your records now but it was a less transparent process years ago and not frequently accessed by patients. With it being a more frequent request of solicitors more hpcs are aware of what they are entering into notes.

tardisjumper · 24/01/2012 19:50

That does sound rough and I would probably be pissed off too. But, as someone who works a lot with health care professionals and knows a lot of them, he was probably just one of the 'not great with people' doctors that are more common in a cartain generation. Or he was having an off day, or he was having an off year. Or he's just one of the duds of a medical profession but has sucessfully helped thousands of people. Or he saw loads of people who really didn't need his help that day while his parter was off seeing loads of serious emergencies.

Either way I have been ill on a number of occassions and had ill children seen before me. Everytime I have been pleased to be part of a health care system that does that.

Dread to think what mine would say. I had the worst gp practice ever when I had a problem that was wrongly diagnosed for 6 months. For me it meant agony and difficulty gettin to work as it impeded my ability to walk. To them it was an uncomfortable non-fatal problem in an overloaded system. its crap, but if I wanted more then I would just have to cough up for a different system. Eventually I got seen by the best docotrs in the world free at the point of entry and have been treated well and cheaply by all the doctors I have seen since.

So I won't be requesting mine!!!!

Lilithmoon · 24/01/2012 23:29

de·ny (d-n)
tr.v. de·nied, de·ny·ing, de·nies

  1. To declare untrue; contradict.
  2. To refuse to believe; reject.
  3. To refuse to recognize or acknowledge; disavow.

reference

BluddyMoFo · 24/01/2012 23:31

This reply has been deleted

Message withdrawn at poster's request.

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