Medical records

[Teenagecrisisagain]

I had an appointment with a doctor at the hospital
Notes were written and everything spoken about was recorded in front of me.

I have since requested a full set of my notes and this consultation is missing. Nobody can find it
It was suggested that I did not see a doctor that day and I replied that I did and saw the notes
I ha e other paperwork from my medical records referring to this appt but still Iam being told there is nothing recorded for this day

AIBU to take this further ? Iam very frustrated and need my full set of notes.

[Threesquids]

You have to pay for medical records, they all set their own fees.

[Teenagecrisisagain]

You have to pay for medical records. I wanted to view and pay just for what I needed but they said no I had to pay for all

I asked was anything being withheld and they said no (was advised to actually ask the question as they ha e to answer honestly) so i know it's not that

[Pseudonym99]

I already requested from medical records and paid the fee for everything

I was under the impression that the NHS are supposed to provide information for free these days. Unless it is something particularly onerous for them to do.

[Pseudonym99]

Had you opted out of the Summary Care Record

This will be nothing to do with the Summary Care Record, or opting out of it. If you have a medical consultation, they are legally required to keep a record. The only way you can opt out of having medical records is by not having medical appointments and consultations.

You can refuse to share information between different organisations, but to do this you need to know records are going to be shared, and pro-actively tell them you do not want information shared. This information is not volunteered by Healthcare staff.

It sounds to me that they do not want you to see this particular piece of information. They could be withholding it to 'protect you from harm'. I think before you tell Healthcare staff anything, you should receive something akin to a police caution - that information will be recorded and possibly could be detrimental to you. I am always very careful about what I tell them.

[Pseudonym99]

freedom of information act which says you can have your notes

That will be the Data Protection Act, not the FoI Act.

[Teenagecrisisagain]

I've gone through all the extensive notes I do have and found the appointment for which I want my notes referred to many times

I've highlighted other relevant info and a really sad letter from 18months after the incident where I'd had to attend hospital and had asked exactly what had been done (method of procedure) as even that had not been disclosed to me. Makes me realise just how awful the situation was
I will take what I have to my therapy appointments and try to work with what I've got
I will still be going in to view the actual file as the gap from the missing notes will be quite obvious

I just feel so down about it all. I just wanted to work through it all and seems I can't even do that easily

[Teenagecrisisagain]

I have explained to them why I want my notes and that its for PTSD therapy not any sort of complaint

[Teenagecrisisagain]

Yes it was written in the fold out section of my notes so was always in there and attached to the rest

I do not know the name of the doctor but think it is in the other notes I have
The only thing I can assume is that it's been removed for a reason. At that appointment I was very clear about an aspect of my medical care
Two weeks later as an inpatient the procedure I had not wanted was performed. My recollection of that is hazy as I had a uti at the time and other problems but at the appointment previous (that is like the notes for) I was of sound mind

I assume they looked at them after the event and panicked as it was clear errors had been made and informed consent not given as I was unwell, the request did not come from me and I was provided with no info to read prior to procedure. I didn't even remember signing consent but there was a form in the notes I received

[Scarydinosaurs]

for the purpose of your therapy- can you create a sheet of notes that records what you remember happening that day?

I know it's not a true solution, but for the purpose of what you want to do, it fills the gap?

[ayria]

This is so unfortunate, I'm so sorry
This is not the first time I have heard of notes going missing either.
Did the doctor you had the consultation with file the notes in your folder? Would they have been taken out for any reason for someone else to go over? And maybe haven't been replaced... Do you know the consultants name? Have you spoken directly to them? Would anything that was discussed in your consultation be mentioned in a debrief? Or was it for further action?

I understand how much it would mean to you as I also have birth related PTSD and also in therapy.

[Teenagecrisisagain]

That's awful threesquids

[Threesquids]

I had eclamptic fits in a very well known London hospital which was solely down to them not monitoring my during a very long and complicated labour.

My WHOLE notes were never seen again after this date!

Since then and with my two other children, I have photocopied and asked for photocopies of everything.

[Teenagecrisisagain]

It's one page. Probably the most important one :(

I know it doesn't change anything having it but I so needed to go through all of this with my counsellor. I needed everything In Front of me and to go through it all and try to process it

The frustration and time spent chasing up this o e page is just causing stress and a delay in my therapy

[stairbears]

Not the first time I've heard of maternity notes going missing unfortunately...

[Taylia]

Had you opted out of the Summary Care Record: There is a new Central NHS Computer System called the Summary Care Record (SCR). It is an electronic record which contains information about the medicines you take, allergies you suffer from and any bad reactions to medicines you have had.

The national SCR system doesn't have any clinical data on it at all, it's only demographics, GP etc. It's been the same way for all of the 7 years I've been using it.

[Teenagecrisisagain]

The hospital made a massive mistake yes but I don't want the notes to complain or anything g like that

What's done is done. It's affected me terribly and I need to work through it all as part of my therapy. I need all the relevant notes to go through and to process what happened.

[HackerFucker22]

Does it involve staff negligence at all? Are you concerned someone has tried to cover their tracks?

(I'm basing this assumption on your mention of PTSD and needing therapy)

[Teenagecrisisagain]

Originally I asked to view records and then say which pages I needed copies of. This was declined and I was told to pay £50 for copy of all records.
I did this but a page was missing so I contacted the hospital repeatedly and they could not find it/say there was no appt that day other than a scan
I have now asked to see the original folder myself as I know exactly what section the notes were in and it will be very obvious if they've been taken out as it goes in date order and all midwife and Dr consultations were recorded in one section so there will be a gap of its not there

[Scarydinosaurs]

Could you ask for the original book?

[Teenagecrisisagain]

No it was all recorded by hand in maternity notes. This is the only page missing though

[blueteapot]

Did thy dictate a letter to GP? Would a copy of that help?

[Teenagecrisisagain]

No I had not opted out of summary care

These were hand written notes secured into maternity file. Everything else was given to me except that

[Teenagecrisisagain]

I already requested from medical records and paid the fee for everything

It is puzzling and frustrating as I know what was written and who I saw. There are many other parts in notes where the appt is referred to so I do not understand why it is 'missing'
I will write in again and I've insisted on going in to look through my file myself

[Creampastry]

Had you opted out of the Summary Care Record: There is a new Central NHS Computer System called the Summary Care Record (SCR). It is an electronic record which contains information about the medicines you take, allergies you suffer from and any bad reactions to medicines you have had.

Have you submitted a subject access request - legal right, sample letter below:

[Your full address]
[Phone number]
[The date]

[Name and address of the organisation]

Dear Sir or Madam

Subject access request

[Your full name and address and any other details to help identify you and the information you want.]

Please supply the information about me I am entitled to under the Data Protection Act 1998 relating to: [give specific details of the information you want, for example

your personnel file;
emails between ‘A’ and ‘B’ (between 1/6/11 and 1/9/11);
your medical records (between 2006 & 2009) held by Dr ‘C’ at ‘D’ hospital;
CCTV camera situated at (‘E’ location) on 23/5/12 between 11am and 5pm;
copies of statements (between 2006 & 2009) held in account number xxxxx).]

If you need any more information from me, or a fee, please let me know as soon as possible.

It may be helpful for you to know that a request for information under the Data Protection Act 1998 should be responded to within 40 days.

If you do not normally deal with these requests, please pass this letter to your Data Protection Officer. If you need advice on dealing with this request, the Information Commissioner’s Office can assist you and can be contacted on 0303 123 1113 or at ico.org.uk

Yours faithfully
[Signature]

Get a receipt for this letter if you hand deliver it.

[Teenagecrisisagain]

I have received a copy of the whole maternity file minus this one page