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AIBU?

Share your dilemmas and get honest opinions from other Mumsnetters.

Original poster

Medical records - AIBU?

36 replies

AuldJosey · 30/04/2019 01:33

So, I went to a consultants appointment a couple of weeks ago and he had a file as thick as a ream of A4 paper in front of him - apparently on me.
Do hospital departments collate all your information on one file?
I suppose I expected just a referral letter or something. Not an encyclopedia. I have been in a coma for a couple of weeks, so maybe all that information is there?
AIBU to think that he should have just brought out my referral letter? Not the book of the damned???

OP posts:
Notanidiot · 30/04/2019 01:40

In the hosital district that I am in there is just hosital file on me. Due to having been in hospital on quite a few occasions it now wuite a big file!

Whichever hosital in the district I go to for an appointment or for an operation, it is sent there. for the doctor tso that whatever new bit of information will be added to it

WilsonandNoodles · 30/04/2019 01:42

There could be links between your current medical issue and historical ones that you are unaware of. Its good to have your dull notes so when you see the doctor if anything comes up they can immediately look back and find any required details. They could deffinately do with getting notes onto a digital system though. Half of hospital space must be taken up just storing notes.

Original poster
AuldJosey · 30/04/2019 01:44

Well good look to him trying to wade through War and Peace!

I didn't realise they kept paper files anymore.

OP posts:
Notanidiot · 30/04/2019 01:44

Fat fingers strike again!

What I meant to say is that maybe things will be done electronically in the future. But at moment they maybe can't go and scan everybody's information from years ago. So the file needs to be kept and sent to next interested doctor so they have all the info if needed.

Original poster
AuldJosey · 30/04/2019 01:46

But where would you even begin to look through a file that thick?

OP posts:
BlueSuedeStiletto · 30/04/2019 01:51

The hospital I used to work in had paper records. Big card file and every admission's notes added in. So the longer you've stayed in or the more times you've been in, the bigger the file. This was only 4 years ago so I doubt much has changed. Most hospitals still hand write a lot.

Even if it was digitalised a good consultant will skim throgh all your notes, regardless of apparent relevance. I know I read as much as I can about a patient if it's available. Its nothing to worry about, in fact it's best practice Smile

pickme · 30/04/2019 02:12

They look at the top of the file for the latest info and within a few pages will be a clarking. Remember all those times you think I have answered the questions before and fume! Well that's why! It is at the top of the file. I work with electronic records and they are fucking impossible to find the latest notes as they have multiple folders and I have no idea why but not one system I have worked with holds them chronological. Paper notes I actually far easier to use but not easy to store and if you have multiple appointments then there is the issue of physically moving them.

Original poster
AuldJosey · 30/04/2019 16:12

I suppose when I was giving him my history, he flicked through a bit. But you forget half of your history, and you can't really expect someone to read through 1000 pages in the 5 mins they have before they see you. For e.g. I forgot that I had had multiple organ failure. I told him why I thought was relevant history, but of course it might not be remotely relevant and I might have missed out on relevant stuff.

And how the hell can anyone read 100 different types of handwriting!

OP posts:
Original poster
AuldJosey · 30/04/2019 16:13

What's a 'clarking'? Like an index or something?

OP posts:
sammylady37 · 30/04/2019 16:25

As you said, ‘you forget half your history’ so it’s extremely important that your consultant has access to your file to find your history. As well as the handwritten notes, there will be correspondence to/from your GP and possibly between consultants and they will provide handy summaries and negate the need to read every handwritten entry.

DaveMinion · 30/04/2019 16:39

Still all paper at my trust. Notes are split into categories like letters, doctors notes, inpatient records, surgical records and results (although results are all online now).

Clerking is when someone is admitted to hospital, a doctor writes down all relevant info about the pt, ie reason for admission, past medical history, social history, medications.

DaveMinion · 30/04/2019 16:43

Ps I work in theatres so see a lot of pt records. Have to find relevant info during surgery for surgeons sometimes can be a pain lol. Especially if someone has 3 folders!

Original poster
AuldJosey · 30/04/2019 16:47

Sounds like my idea of hell. Used to work for a solicitors and roaming through paper files (I'm allergic to dust) was my idea of hell). I fucking hated it.

I suppose I was surprised to see my entire medical history plonked on a desk before me.

OP posts:
sparkli · 30/04/2019 17:10

I'm 42 and onto my 4th file. It's a standing joke when I have an appointment with any of my consultants Blush

redstapler · 30/04/2019 17:54

I have been in a coma for a couple of weeks

You've been in intensive care for a fortnight? Um, yes, that will have generated quite a lot of notes! Did you not think they would keep records of your care?

And TBH if you don't think a history of multiple organ failure is relevant then with respect you can't really be trusted to give a decent history and he needs the notes.

LikeDolphinsCanSwin · 30/04/2019 17:56

You think it is unreasonable that the consultant has your notes? Do you really think that, or are you just trying to think of things to make threads about?

OVAgroundWOMBlingfree · 30/04/2019 18:02

AIBU to think that he should have just brought out my referral letter? Not the book of the damned???

YABU, unless you would like medical professionals to do a slapdash job and rely on patients for all history - especially patients admitted to ICU.

Either way I hope you are making a full recovery.

BettysLeftTentacle · 30/04/2019 18:08

We don’t work with paper files any more in our Trust but the 2 weeks in a coma in ICU on its own, will have generated a shit ton of notes. The notes will be sectioned into categories and the consultant will know which section to look in and the most recent entry will be on the top. It wasn’t unusual for a person with a long and complex medical history to have 6 or more sets of notes. So glad we don’t have those anymore!

Nicketynac · 30/04/2019 18:09

I work in an ICU and we have an electronic system that automatically produces an A3 sheet for each day of an admission, all your meds, blood results, BP readings, ventilator setting etc. Nobody would read through that unless they were looking for something specific, they would read the discharge summary which should include all relevant details.
We are moving towards electronic records in the rest of the hospital so everything is scanned in as well. Not sure when we will get rid of the paper though as it can actually be easier to search through.

BettysLeftTentacle · 30/04/2019 18:12

A referral letter won’t give a detailed PMH and as you’ve already noticed, you can’t always rely on a patient to give one either. It would be pretty shoddy work to try and investigate or diagnose without a full past medical history.

AuchAyeTheNo · 30/04/2019 18:16

Would you rather the consultant just listened to what you though was relevant?

YABU and I bet you would have complained or been on here moaning if something major had been missed!

MumW · 30/04/2019 18:16

And TBH if you don't think a history of multiple organ failure is relevant then with respect you can't really be trusted to give a decent history and he needs the notes

To be fair, the OP said she'd forgotten about the organ failure and admits she would really know what was and wasn't relevant.

MumW · 30/04/2019 18:17

wouldn't

collectingcpd · 30/04/2019 18:18

I’ve had patients with 4 files.

Walnutwhipster · 30/04/2019 18:19

Mine run to volumes. I know because I've seen them. They don't all come to each appointment.

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