To be so cross and upset that I'm going to see the doctor tomorrow

[ScrotesOnFire]

And try and get an item removed from my medical records?

I can't go into any detail for fear of outing myself, but I saw my midwife today and she brought up an item on my records.

From many MONTHS ago which means that she must have been nosy and been rifling through my medical history in order to come across it

I was not aware that this information had been shared, I would not have given consent for it, it has no relevance to my health, was dealt with long ago and can only possibly be used to cause me distress, not improve my care in any way, shape or form.

I am absolutely furious that she has been rifled through my history like this, who else is this information open to?!?!
Any midwife, nurse, doctor, receptionist etc could read about it.

I haven't been able to relax all day about it, I am so upset and distressed.

I feel like not seeing my midwife ever again. Or the doctors.

Feel violated actually.

Hi OP, if you are still reading.

Sorry that you are so distressed. Please talk to your GP. We cannot falsify records so cannot always remove items, even if they are distressing. However, sometimes information becomes irrelevant and can be safely removed or - if it is very sensitive - sometimes it can be hidden from the everyday view of your records.

Some examples (please don't think I am assuming any of these are your issue - it's just to illustrate): if a patient had been convicted of drunk-driving, this might be very relevant to medical care at the time if she was in the middle of being treated for alcohol addiction or if she was very depressed as a result of the conviction. . It might also be a child safeguarding issue is she was driving with the kids in the car. However - 5 years later it would be highly unlikely to be relevant to the medical records and could probably be removed.

Or, a sexually transmitted disease many years ago. That shouldn't be removed because occasionally STIs can have long-term consequences but it can be marked as "sensitive" which means it doesn't show up to someone just scrolling through the record.

Unless you're trying to join job such as the forces where medical records matter, then who cares? I'm sure they know much more about other people and manage not to blab. Stop being so narcissistic, they really couldn't give a toss about you in the long term!

Ah OP I'm sorry you're so distressed.

May I gently suggest you try and sit and ponder why this has brought about quite such a violent reaction in you, before going in all guns blazing tomorrow, when most other posters are suggesting it is a fairly normal thing to have happen?

I was attacked many years ago. Medical intervention was required and it's in my notes now. I hate that whenever I catch sight of it. Hate that these strangers know this fact about me. But I accept it is part of my history. No one is trying to snoop or undermine you, they don't even know you, they've no motive other than to carry out their role of caring for you and I hope you can find a way of seeing that.

You're pregnant. If you remove yourself from their care because they won't remove this record, I can imagine that you risk raising safeguarding concerns re the baby. If you go in as upset and angry as you clearly are now, you are unlikely to convince anyone of the irrelevance of the matter to your health.

Why is it on your medical records if it isn't medical or mental health related? Your medical records will be transferred to your next healthcare provider, and if you are pregnant and remove yourself from any form of medical care it will raise red flags to the healthcare professionals, and make them focus more attention on you.

But with a note on about how you reacted to this! Which will mean people will be more cautious what they show you is in your notes

What? Patient asked question - how very dare she! As long as it done politely, there's no issue with that

Under the DPA, you can request a copy of your notes. There are very, very few legal exceptions (quite rightly) which allow information to be withheld

There is no problem with a midwife going through all of the medical notes..they should do .

You're obviously very upset, but your threats of 'never using them again' isn't going to harm them, only you. Don't cut off your nose to spite your face.

She may well have not trawled through the notes to find iinfo, depending on the system used by your practice the computer can produce summary for the person using it....I'm a district nurse and the system we use brings up recent appointments and relevant past medical history, and any information that may be relevant to my consultation.

Whilst I appreciate that this was really shocking for you, please sleep on it, the mw is a professional who is there to help you .

They are legitimate questions, yes. But I suspect OP already knows why it found its way onto the record.

GPs don't have time to write down every bit of news a patient tells them. I may occasionally write in clinic "Mrs X is going to Nepal", but only so I can ask the next time "How was Nepal?" But a midwife wouldn't then say "Oooo, you told Dr Livewyre you went to Nepal!" Or if they did, it wouldn't be threadworthy!

It must have been something necessary to write down (alcohol misuse? DV? Court case in the family?), and this may be relevant to risk to a newborn.

Unless it is incorrect, ie. an error, like the example where it was clearly the wrong notes, it will not be removed, for ethical reasons.

Gobbolinothewitchscat
The tonsillectomy 30 yrs ago may actually be relevant. For e.g if there had been general anaesthetic complications; this would be useful information if the OP needed a CS under GA.

You see so many women suffering with antenatal or postnatal depression and left to struggle on their own. I am sorry, but a midwife who is trying to get a full picture of her patient to help care for her sounds lovely and professional.

Medical professional have the right to know about anything that can affect you and/or your baby, they are just trying to help you. It's fine to tell them that the issue has been resolved and you refuse to talk about it. Don't blame them for trying to be thorough. They would be blamed if they didn't.

Don't take up a dr's appointment for this. Practice manager is who you need.

Raising it as an issue won't get it removed. It may get you labeled as 'that sort of patient', and the info hidden in your notes where you don't see it. For goodness sake, it's entirely legitimate for patients to raise concerns or discuss any issues that they might have. HCPs are not God. They are allowed to be questioned. As I've said above, I would be interested to know exactly how this information has made its way on to the records and the exact reason that the midwife was looking at/for this information. These are legitimate questions for the OP to ask.

This. No one is going to "hide" information (except by marking it as sensitive if that's what the OP wants). Errors do creep into notes and it is very important that patients can challenge them. Hopefully, within the next few years, people will be able to view their own records electronically.

Gobbolino (Storyteller?) Midwives don't have time to go through everyone's notes like this. Mine rarely bothered to get to grips with my maternity notes

Storyteller - yes

Well, quite. I've had 3 babies in the last 3 years and I would say that 90% of the midwives have been rather hopeless (evidence based conclusion) who couldn't be bothered to keep on top of the basic checks they needed to do so I could hardly see them putting themselves out to do any further reading

OP - are you having consultant led care?

shineynewusername- made inactive, or moved into another area, is not the same as 'removed from the records'.

You should not be removing anything from the records, unless it is actually incorrect (e.g. an asthma diagnosis when they had post-viral wheeze once as a kid, could be marked in error, and the problem title changed, this would all have an audit trail, and the original record never disappears).

Changing the contemporaneous record, in the future, would land you in medico-legal hot water.

sadly it seems like the information is accurate although not something you want discussed.
I doubt it is legal to erase/delete the information (if accurate and something you discussed with the physician) but you might ask for it to be marked in the notes as a topic that is not to be discussed by staff other than the physician himself.
you can then discuss if you would prefer to continue with the same midwife or see another.

This is why I'm loath to mention anything to do with my mental health to my doctors anymore.
Everything you say is documented and set in stone.
The repercussions are simply not worth it.

The midwife probably just clicked on the summary of significant issues - these are subdivided into major and minor and just appear as a short list. I doubt she would have had time to scroll through notes.

I often do this - for example many patients can't remember what sort of heart operation they had ten years ago, or the exact type of cardiac device they have got in their heart - but it would be important for the HCP to check. I only look for anything that would be important for me to know and I wouldn't mention anything else.

Yabu. Tbh sounds like it might be a flag up as I doubt the midwife would have time to go through months and months of notes. If it linked to mental health that is part of your health records. Yanbu to discuss this with your gp but yabu to be angry with the midwife. Shes treating you and needs to know full medical history. If this note is factual you cant get to removed from your medical notes. You right through to talk to your gp.

The tonsillectomy 30 yrs ago may actually be relevant. For e.g if there had been general anaesthetic complications; this would be useful information if the OP needed a CS under GA

I think that's pushing it somewhat! my DH is a dentist and is assuming that doctors' notes work the same as dentists. Anything of import - edge don't give patient X drug X or they will DIE is flagged up on the system. You don't have to rifle through 30 year old notes to check if they've had a bad reaction to an LA when they were 7.

I could imagine all sorts of things that would have a knock-on effect on the OP's mental health. GPs who are good will signpost patients to all sorts of other agencies. Perhaps the OP had occasion to need debt counselling or a referral to a food bank or something that now brings back very bad memories. It could be something that's triggering for her because of her circumstances at the time.

OP yanbu to be upset but I would try your best to explain why and ask GP what they can do.

If in doubt you could speak to the information commissioner for advice

shineynewusername- made inactive, or moved into another area, is not the same as 'removed from the records'

Agree but I am assuming from what the OP has said that this is not an entry in the notes (which I agree must not be altered unless wrong and then only with careful documentation) but some sort of additional document from an external agency. These don't have to be held in the EPR - especially if they include 3rd party information.

For example- a patient goes through years of fertility treatment, then adopts. They want to get on with their lives, without everyone who sees them knowing their past issues.

All the fertility stuff could be made 'inactive'. This effectively 'hides' it.

But it's still there. It's not deleted.

But who goes looking?

Similarly, no one is going to look back to when Livewyre cried because her dad had cancer, and needed a week off work because it was all going wrong, in 1996.

OP- I would speak to your midwife and ask them to explain why they think this info is relevant to your antenatal care. Because they obviously think it is. They don't have time to flag up " Scrotes bought a new car in 2003!" Which would be an actual non-medical irrelevant fact.

if anyone reacts that strongly about this, the issue has very obviously not been resolved, and proves the medical team really needs to be aware of it!