Reading your own notes in Hospital

[QueenSconetta]

I was in for a day op on Thursday, and a couple of the other patients were told off for reading their notes by the nurse. She said they could request a copy of them but they were not allowed to read the ones which were there.

AIBU to think this is a bit bizarre? It is more likely IABUninformed. Anyone know why your not allowed to read your own notes?

Because they are confidential information just as other peoples notes are

That sounds very odd to me, why would you be forbidden to read something concerning yourself? Are patients then given an edited version where the staff have deleted all the comments about how surly and uncooperative they had been?

Does sound bizarre - I have often read mine when bored.

I always read mine, and they are always, a scary work of fiction.

But surely it's confidential information about YOU so you should be entitled to see it?

If you can have it through a copy, then why can't you just read them when they are there?

Also they weren't tucked away, they were on the table right beside them so they were probably only looking at them for something to do.

Because it comes under Data Protection and they can charge you for a copy of your notes - same with school records etc.

I read mine. You should be able to read them they're about you.

They don't like it because you may find stuff they've written that you won't like.

As far as I know, you are allowed to read your own notes. I think the nurse was wrong to say that.

It's true, patients aren't allowed to read their notes willy nilly, they are property of the hospital. Even if you requested a copy of your full notes through the proper channels the hospital doesn't have to include everything but can leave bits out if they deem it necessary

I believe that the system is meant to work such that if you request access to your notes, you are allocated an appointment with a doctor to go through them, explain shorthand or odd phraseology etc, in an attempt to avoid upset / misunderstanding.

Reading them through without a medical dictionary could lead to problems (for example if you don't happen to know that TTFO stands for "tablets taken, fluid orally").

Teabrick you are wrong. You need to apply through the proper channels to read your own notes

Under the Freedom of Information Act - they cannot selectively remove bits of your notes

www.ico.gov.uk/for_the_public/topic_specific_guides/health.aspx

As a midwife I'm happy to give inpatients their notes if they want to read them. I wonder if part of the problem though is the possibility that people might remove parts of their notes. I have honestly known this to happen. Then they could complain about xyz and the hospital have no proof it didn't happen like that.

The reverse of this is that i've asked to see my notes, been told they were 'in use' and when i was finally given them a few hours later the pages I wanted to read which would have proved my later complaint had mysteriously disappeared.

I had a Day Case op and read my notes while waiting. The nurse reprimanded me and took them away! Luckily I'm a speed reader and had finished

I always photograph my notes (with my phone.)

I think they might get a look that unmistakably said Sod off.

I photocopied all my green maternity notes and as I had a Home Birth the nice MWs let DH do the last pg. Before they took them.

My normal notes are very very dull.

I've still got my maternity notes. I made a complaint against the midwives and asked them not to come back, and they didn't collect them. I didn't know that Fut, I always thought it was ok to read them.

What´s the reasoning behind it?

Surely there shouldn´t be anything in them other than what you already know about your illness/treatment etc.

I don´t get the big need for secrecy, or that if you request to see your notes they are not just handed over.

Viva

wonder if part of the problem though is the possibility that people might remove parts of their notes. I have honestly known this to happen.

Yes it seems it works the other way too with editing or removing of your personal notes by hospital.

Its disgusting and almost Kafka esq - we should all be allowed to read our own notes. Data protection v freedom of information.

This is how bodies can cover up and mis lead you, it should all be transparent and above board. Infact we should be allwed to make our own comments in our notes.

So what if you are on a ward and dont know what TTFF is - you shoudl be able to simple ask the nurse the next time she attends you!! AS she is taking blood pressure or something surely she can say - " oh yes TTFF " is x, y z.

what utter tosh.

I have just gone through my blloody notes after FIVE YEARS and it turns out my baby was back to back.

I am disgusted I didnt know this at the time or after.

What would the situation be if the nurse told you not to read them, and you did anyway? Would security be called?

The reason why patients are discouraged about reading their notes on their own is for two main reasons:

1. There may be information about someone else in your notes that should be removed before the patient sees them.

1. You are encouraged to go through the notes with someone who understands medical notation and terminology.

Whenever I write in notes, I am always conscious that patients might read my notes and often offer to send copies of my clinic letters to the GP to the patient, but I write them so a doctor will understand them, not necessarily a patient.

It's just an old fashioned paternalist attitude to health-care. We are clever, important medical people and you are just a person.

In many hospitals and departments it is common practice to give all patients copies of letters/scan results/blood results. It is a move away from doctors 'owning' medical information and giving back power to patients.

In my area - Oncology - I implemented the policy of cc-ing any patient who wanted in to every letter about them and made a copy of every scan result for them. They were always free to read the nurses notes. Each consultant had given permission that anything thet wrote could be read by the patient. I got the idea from the Royal Marsden, I'm not sure it's policy there but certainly some consultant behave like that.

You have to remember not everyone wants this information so it is an 'opt in' situation. It went down really well were I worked.

There was one particularly arsey surgeon who made people apply for their notes (and pay for the priviliege). He really didn't 'get' how it was any of their business

There shouldn't be anything in the patient's notes that is 'inappropriate' for them to see. Some doctors and nurses (rarely) like to be discriminatory, derogatory and offensive and don't wish to be called on it.

The only area of medicine this is not appropriate is psychiatry where obviously receiving some information may be detrimental to the health of a patient.