Mistakes in medical records - to chase or no?

[RevoltingPeasant]

So I discovered this morning that there are mistakes in the records held by my GP surgery. They have a whole long history of childhood immunisations which I know is wrong.

They said they received that info from my previous surgery and just inputted it, so they're not responsible. Fair enough! So they said I could just leave it as a mystery or chase it with central NHS records office.

More of a WWYD I guess. I am not sure I see a benefit in correcting it, as I am quite old late 30s now and does anyone care about childhood imms at my age???

So AIBU to leave it? Or can having mistakes in your medical records cause some problem I haven't thought of?

It could be relevant if you get pregnant.

Some childhood illnesses can be dangerous for adults or unborn babies.

My GP had notes that I was involved in a large and distressing plane crash. Only found out when I went to discuss contraception regarding a holiday and the nurse commented how brave I was getting back on a plane. Still I and they have absolutely no idea how that information got on there

I would probably chase it and have it corrected just in case.

I guess there has been an error somewhere along the way - it may be relevant to the future for you but alerting the practice to it may also prompt the surgery to look at their systems of data inputting etc This may have happened to others' records with potentially very serious consequences.... e.g. Missing out someone's extensive cardiac history/allergy status etc

One of my dc has a whole load of wrong information on their file. Have brought it up but they're not interested as mistakes do not happen.... They are pretty rubbish generally though and probably can't cope with the amount of correspondance he generates (SEN).

I'd get it corrected, particularly if it shows you'd had jabs you haven't had, just in case you might have an allergy.reaction you do't yet know about. Eg if someone who's had jab A with no reaction, then jab B is safe for them- your notes look like you had A but you actually haven't?

I don't believe they can delete anything - Just add notes saying that you believe it's incorrect.

You could ask your GP whether they can add a note or appendum that you believe the information to be false.

How important it is depends on what the false information is, I think. Is it for jabs that you have never had? In which case I think I would pursue it. Or ones you had at a later date, I would be less inclined to bother, unless it is a jab where you might need a booster at some time.

How do you know the information is definitely false?

Okay, thanks all!

DrMum they were very nice about it - the practice manager had his first day back at work today after a few weeks off and made me an appt for 9am, and was very puzzled about it all, went thru my paper notes with me and everything. It is pretty demonstrably wrong as my 'official' paper notes have no record of these imms and yet there are all these very specific dates like September 22nd 1987 and stuff.

Anchor it's definitely wrong, though. I know because although I was born in the UK, I did not grow up here - moved abroad literally as soon as born - and moved back to this country in the late 1990s. All these dates of supposed jabs are from the 1980s when I did not live here or have an NHS GP or any NHS record.

I believe that either they 'spliced' my records with someone else's - maybe when records went digital in, when? the 1990s some time? - someone looked at my records and thought, 'she MUST have had her jabs' and found the NHS records of someone with a similar/ same name and conflated them....or just 'predicted' when I would have had them based on my age.

They probably thought I was a super healthy kiddo with no medical records at all apart from being born whereas in fact I was on the other side of the world!!

My notes say I come from a dysfunctional family background. I noticed when I was 13 and by myself. I pointed it out and told them we were a happy family and nothing dysfunctional about us. Still a little at that. I know one sister was a bit of a trouble maker and had depression from early teens along with suicide attempts but that was her and her illness, not my whole family.

They won't be able to delete it entirely because it is part of your record, because doctors and nurses will have seen you in the meantime and may have based their care on that (incorrect) information. Eg if Dr X falsely believed you had received a tetanus jab when they saw you with aa dirty cut in 1995, if you remove that entry, it looks like Dr X had been careless in not giving you the jab then.

BlueRaptor yours is so random!!!

I recently found out that my records said I had a brain aneurysm! First I'd heard about it! GP checked and thankfully it had been added by mistake but agreed that it was a fairly major thing to have wrongly added to someone's medical records. Also makes me wonder about the person who didn't get it added to their records- surely their doctors would need to know that information?!

Oh I see Gu - great name - actually that makes sense. I was thinking it was a bit authoritarian!!! Like, well we SAY you had the jab...when in fact, I was 3k miles away and clearly could not have had it...........

But yes of course, it would have potentially had knock-on effects. I think I will chase this with the nice practice manager.

Does anyone know how to contact that central NHS record office he mentioned? Would I have to make a complaint? Would rather not as they are a good surgery.

The surgery should be able to give you a form to fill out. Def chase it - I had to be reimmunised at 22 and knowing what id had originally was relevant (even though I was no longer immune...)

My surgery has lost an entire a&e admission for my dc. So naturally their take on it is it didn't happen, my dc didn't have extensive xrays and tests and so the fact it's turned into a chronic issue doesn't need dealing with as 'this is the first occurrence we only treat it if there are multiple or major episodes that require hospitalisation'

The fact they are the only surgery not on the autoupdate system the hospital has is just a coincidence...

So yes. Complain.

Hi all - thanks - so update

I have rung half the bloody country NHS England and various people who finally arrived at this conclusion: I can go to the practice and get the senior GP plus practice manager to witness a note on my medical records stating that 'I believe this information to be incorrect'

OR

I can make a formal complaint and that will allow me to see who inputted this information originally.

WWYD? I do not want to make a complaint that will give the surgery hassle as they are very good and I know these things are a pain when a patient complains.

On the other hand, how seriously will anyone take a note that says 'patient believes x'? I mean, I KNOW the info is wrong so is that strong enough? And I would like to know who added this info!

I would make a formal complaint. It's a genuine complaint and you are not being a timewaster. It's not your fault the mistakes were made, and you have the right to have the correct information on your records, not just a note that you "believe" something.

Do it formally, you never know when this information might be needed. And the patient is never believed!

You'll probably have to pay a fee to access them

Is there any way that you can supplement the note by saying that you believe it to be incorrect because you were living in X location between YY and YY. That will make it clear that the chances of the record being correct is minimal but without a formal complaint. Maybe suggest to nice practice manager.

The fact that the dates are so specific makes me think this quite a large mix-up (potentially even a systematic one), so making a formal complaint to enable them to unpick the whole thing may be important.

It's a shame to give them work, but will be more of shame if someone suffers badly inappropriate care because of an incorrect record.

Did you have vaccinations in the country that you went to live in op?

I often note on our computer system at work vaccinations that children and adults have had in other countries before they have joined our system. Is this what may have happened or do the dates contradict your baby records that you/your parents have kept? Sometimes we have no medical notes but take vaccination records from cards that parents keep.

If you have had no childhood vaccinations there is a catchup schedule for everyone and I would say it would be good to speak to your practice nurse about these especially with things like measles outbreaks.

Apologies if I have misunderstood.

Mistakes do happen and notes can be annotated to note this.

Idefix I did have jabs abroad - I lived in the US where they are required for school - but I do not know how the nhs would have accessed my paediatrician's records so I don't think it can be that. I have never given the nhs this info and my mum says she hasn't either. All my US medical records that we had were destroyed in a flooded house in 2002 and the practice manager coild see that the info had originally been inputted in 2003.

My old paediatrician died in the 1990s around the time I returned to the UK but he would not have randomly contacted the NHS to tell them private medical info about me without my consent, so I don't see how this can be right.

There is just a chance it could be though....which is why I want to know who put it on the system!

Make a formal complaint. They really should find out what happened. You could add a line saying that you are happy with the care you have received from the practice maybe?

I think these are possibly your injection dates that have been given some how although intriguing as not given by you or mum. We do occasionally get transcripts of records from other countries, esp USA, Canada etc and these are usually summarised on to your records.

As you move from each gp practice your Lloyd George enevelop of paper records and a print off of computer records are sent off via a central records place and the next practice is meant to summarise your notes and put what is significant and important on the system.

This does not always happen in a timely fashion especially where there is a high turn over of pts - uni doctors, military towns, big cities or just bad practice.

I have found things in paper records that have not been put on to computer systems and added them, but clearly many, many years after computer records have been in place. Summarising is hugely time consuming process and mistakes do happen, due to human error and terrible doctors handwriting

Not trying to make excuses but trying to make sense of what might have happened.

I don't suppose the person who entered the records explained or attached a photocopy of the source clutching at straws

Ide but the practice manager got out my paper records and went through tnem page by page with me. There is nothing in them to warrant the vaccine record.

My paper NHS records are really slim - the PM kept marvelling at it and the literally go "197x - born and some newborn bits n bats.......199x 18 and at uni asking for contraception!" There is an 18 y gap in them.

But the online summary has dates thru 1980s and no actual indication who put that info there or why.

It's possible that as a carefree student I earnestly went along to my uni medical practice and insisted they enter all my vaccine records...then promptly destroyed all my own paperwork and forgot all about it! Possible my mum dud the same....possible my old paed randomly (and presumably illegally?) got in touch with the NHS and shared data, although I don't thnk he even knew I came back here.....

But pretty unlikely