Hospital records

[HappyAgainOneDay]

I have a relative who had an appendectomy last weekend. She was progressing well afterwards but has had a setback with swollen legs. To me, this means water retention (I am not medically knowledgeable really) but this condition is not being addressed. She just has paracetamol and nothing else (no tablets to remove the fluid).

Her husband looked for her medical/surgical record (the one usually hung on the end of the bed) but discovered that they are all locked in a cabinet. Is this usual now? I suppose this might be to keep out Bounty-type people on other wards but may he ask to look at it? Should he persist? Should it be readily available for relatives to look at?

It is usual nowadays. Hospital records are confidential up to and including the patient. If you want them, you can apply to hospital for them, but they're not kept openly, and now shown to anyone at all.

Under the Data Protection Act 1998, you have a legal right to apply for access to health information held about you. This includes your NHS or private health records held by a GP, optician or dentist, or by a hospital. You don't have to give a reason.

I suggest your relative's husband asks the Sister in charge, or a nurse or doctor to look at the records. Formally it's called a Subject Access Request. Efficiency ranges across hospitals but don't accept a brush-off. It has been known for records to 'disappear' or be altered when negligence or mistakes have been made. And when I asked for my mother's hospital records, I read with amazement of things I'd apparently said and done (I tore a hospital note in half apparently which was totally untrue - long story I won't bore you with)

Good luck.xx

If you or her husband has a concern you need to bring this up with her doctor or one of the nurses. Looking through her notes probably wouldn't help you unless you knew what you were looking for anyway.

Nursing records are different from medical records which are confidential. Her DH can't just read her hospital notes it's not allowed. However they can ask to look at them with someone who can explain things, you have to apply.

Are they concerned about the swelling? Have they asked the doctors or nursing staff rather than trying to hunt down the notes? If she's immobile and retaining fluid she should be wearing ted stockings and possibly be given an anti coagulant injection every day.

They are kept in a cabinet at the hospital where I work for Data Protection reasons.

Is there a reason why the wife is not allowed privacy.

I may be married but I'm entitled to keep my medical personal to me.

Dr here- Most notes are kept locked away due to data protection rules, so yes that is normal.

Your relative has a right to access her medical records, her husband has no right of access. She can show them to him but he cannot apply to see her medical records (unless he has welfare power of attorney). She must apply to medical records to view them (ward staff should be able to get the forms or at least point you in the right direction). This can take some time and if you want a copy of the records, there is usually a fee to be paid.

As to the swollen legs- rather than go through this lengthy process (or even if you did have ease of access to the notes, wading through them), wouldn't it be far easier to speak to someone in her team and ask what it is/what they are doing about it? It may be nothing serious and will improve once she is mobile again.

And to the poster who said medical/nursing staff falsify/alter records routinely when requests for access are made- I would despute that. It is illegal to do so, and is also likely to get you struck off by the GMC (or suspended with serious restrictions on practice on return, though this is less likely). I'd also have thought fairly difficult to do undetected. I'm not saying it doesn't happen, I'm sure it does occasionally- but not routinely.

Agree with iam
The waynotes are written, dated,time,no gaps-chronological order makes it nigh on impossible to falsify records without it being obvious.