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AIBU?

Share your dilemmas and get honest opinions from other Mumsnetters.

Original poster

Medical records help

37 replies

Answersneeded · 14/06/2017 19:04

AIBU to think that ALL correspondence that is in a patients medical notes should be clearly signed ?
Surely EVERYTHING has to have a named 'author'?

I'm asking because I came across a letter in dcs notes and it's undated and unsigned and nobody will tell me who wrote it. Without a name I can't complain so I'm going round in circles

Surely there's some kind of guidelines (I've tried googling but to no avail) that says letters/emails HAVE to be properly recorded as otherwise anyone could send something in ??

OP posts:
ThatsNotMyToddler · 14/06/2017 19:13

YANBU. May need some detective work. Assuming you're looking through GP notes? Is it a letter to or from the GP? Are they computerised notes or paper?

In all honesty if it's to the GP then they may not know who it's from. Is there a date of when it arrived in the surgery (either date stamp or on computer - they should be able to tell when it was scanned in). Or is there a hospital (or other) letterhead where you could contact the department directly and ask them for help via their own records?

If it's from the GP then you may need to read all the GP notes to determine where it would 'fit' if you like - tedious and probably difficult to do.

Difficult to offer other suggestions without knowing more details - and appreciate you may not want to give them - but sympathies OP, it sounds v frustrating. No name is one thing but no date basically makes the letter a waste of time.

Original poster
Answersneeded · 14/06/2017 19:16

It was an email. Undated unsigned and not addressed to anyone. Was sent to the gp. After a lot of letters and digging I was old it was from 'a nurse' and 'accepted in good faith'
Every other letter or email has a date and is signed this could literally have been written by anyone. It names others as contributing to the content yet all these people deny any involvement too. Brick walls have gone up everywhere and I can't get answers
What I'm looking for is if there's a guideline somewhere or rule stating this type of thing has to be properly recorded and have an author in the notes but can't find anything

OP posts:
ThatsNotMyToddler · 14/06/2017 19:17

Oh and GMC guidance covers drs who must provide appropriate correspondence and info to colleagues/the patient record.

Here: www.gmc-uk.org/guidance/good_medical_practice/record_work.asp

SheRaaarghPrincessOfPower · 14/06/2017 19:17

Is there a reference number on the letter?

Original poster
Answersneeded · 14/06/2017 19:17

I did get the date in the end they told me they could see when it came in but when I asked who from (it was an email there must be a senders name) they couldn't/wouldn't say

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Original poster
Answersneeded · 14/06/2017 19:18

No it's just a couple of a4 sheets and in paragraphs
No address date heading addressed to anyone and signed by nobody

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ThatsNotMyToddler · 14/06/2017 19:19

For nurses is NMC guidance : www.nmc.org.uk/standards/code/record-keeping/

ThatsNotMyToddler · 14/06/2017 19:19

Sounds really shit. Can you not deduce from the contents anything about where it may have come from?

Original poster
Answersneeded · 14/06/2017 19:20

The nursing service it was apparently from would give no information and wouldn't confirm or deny involvement.
Others implicated deny ALL involvement (even though some information could only have been known to them)
Ive even called SS who knew nothing about it and tbh given the appalling (untrue) content they should have been aware. I'm getting no answers from anyone and currently awaiting a response to my second complaint to the gp

OP posts:
Original poster
Answersneeded · 14/06/2017 19:21

Yes I do think it's from the nursing service they allege but I've been told without an actual name I can't complain

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ThatsNotMyToddler · 14/06/2017 19:21

If the practice received an email and printed it off to scan into the notes then they probably don't have the original any more. So if no address on the scanned copy they genuinely won't know. Does sound like that's something they might like to change their practice on though...

ThatsNotMyToddler · 14/06/2017 19:23

I call bullshit that you can't complain without a name. Try contacting them
again and suggesting that the NMC may be able to shine further light upon your query. Smells horribly like a cover-up if they're not being very helpful about it.

Original poster
Answersneeded · 14/06/2017 19:23

But in that case of it's a genuine oversight by the gp why does the supposed service where the author works and others involve deny involvement ? I'm totally baffled

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Original poster
Answersneeded · 14/06/2017 19:25

I complained to the other sources named in the letter as they had given false information. They will not investigate without the full document and name of author but also denied ever giving any information?
Also the nursing service won't even speak to me or reply to complaints so I've done a subject access request but still awaiting that
Gp is going to respond to my second complaint shortly as their first response was unacceptable basically saying they won't remove it from notes, don't know who wrote it and just accepted it In good faith

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ThePinkOcelot · 14/06/2017 19:26

I don't understand this. When I print off an email at work, it has the sender, recipient (s) and date and time on the top before the text. Has this been cut off?

Original poster
Answersneeded · 14/06/2017 19:31

All that was on the top was a handwritted sentence 'please scan to all children's records' the the paragraphs of the letter

When I read it and told the surgery how appalled I was the initial response was "when did you see this? How did you see this ? Do you have a copy?"

OP posts:
ThePinkOcelot · 14/06/2017 19:34

Something sounds a bit off OP.

ThatsNotMyToddler · 14/06/2017 19:38

Yes they're correct in that once something is in the record they can't remove it. They can however add a note to say that you dispute the contents of the email.

I wonder if the source service feel they'd rather not get into it (as you're unhappy) and so are stonewalling with the no name excuse. Sounds like they may be closing ranks on you.

I guess it could be difficult for other services to confirm or deny who said what to whom without details of the source. Not saying that's right mind you.

Having fought my share of NHS admin battles OP I would like to gently ask how important it is to find out the background of this. I'm concerned for you that you could remain (understandably) stressed and angry about this for a long time without getting good (by which I mean helpful) answers to your questions. Would it be enough for your GP to append a 'disputed contents' comment in your dc's record or is there material harm done here?

Please note that in saying the above I am NOT saying that anyone should get away with this kind of thing. Just that NHS admin is often shit and opaque, and there may be little will or ability to find you more information.

Original poster
Answersneeded · 14/06/2017 19:39

I can't get any answers I hoped SS may have been able to help but they didn't know. Given the content although totally untrue they should have known.
It's basically accusing me at length and in great great detail of FII which is completely false. I have pointed out to the gp that they themselves had all the evidence there and would have known that I did in fact have proper diagnosis backed by test results etc etc. The other bits of false information I could either disprove myself or luckily had kept emails that I sent in but nobody will take any notice. Seems that this was sent maliciously and the gp didn't act on it just put it on dcs notes

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MatildaTheCat · 14/06/2017 19:42

The organisation at fault sounds like the nursing service. Go to the top and ensure that you copy in the chief executive etc. PALS are also supposed to assist patients with these types of enquiry.

The GP practice haven't done much wrong here IMO and won't usually remove items from records although you could write stating that X and y is inaccurate and does not meet the Nmw standard on record keeping and therefore should be disregarded.

Original poster
Answersneeded · 14/06/2017 19:43

I have to wait the 40 days for the subject access request from nursing service before I can do anything else as they won't tell me. I have a couple of names as know who the nurses were that I saw but they keep saying without a definite name they won't accept a complaint

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Original poster
Answersneeded · 14/06/2017 19:44

I believe the gp knows the name of who sent it though

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TeaBelle · 14/06/2017 19:45

Where I work, if anyone requests copies of their notes, we can provide tgings written created by our department but can't give any info authored by anyone else. Could this be what's happened? Also, I know it must be hard to accept, but if someone had a concern surely it's a good thing that it was raided but after consideration people felt that the concerns weren't founded. Much of safeguarding is a jigsaw rather than any one person having a complete picture

Original poster
Answersneeded · 14/06/2017 19:47

That's why I called SS ....as much as I hate what was writes as it's not true I do feel they should have been aware and investigated.

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Original poster
Answersneeded · 14/06/2017 19:49

The gp sent the letter to dla as well when asked for his medical notes which now has held up his remewal hugely so this anonymous untrue letter is now causing other issues yet nobody will admit to it or retract it and meanwhile we have to meet all the needs of a child with medical conditions with no dla currently (since December) and this document is holding things up massively

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