Medical records - AIBU?

[AuldJosey]

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???

We have paper notes and generally I’ll just look in our section but I will also look and see if anyone has been admitted under the medics and what they’d said.

It’s amazing how many people will say they are fit and well but have diabetes, have had a heart attack and have lung disease! All drug charts are kept as well as nursing notes, so you can rapidly accumulate a thick file.

Ah walnut I wished our hospital only brought the latest volume. Some patients have their own trolley just for all their volumes.

My daughter had an 8-volume file (each about 8-10 cm thick) by the time she was 7 years old. It came from a very complex medical history and many stays in the hospital that were measured in months. An average day in ICU can generate up to 50 pages of notes, from bedside nursing, lab results, consultants, other tests, attending physician and students' notes.

And, since you were in a coma, you can hardly be a reliable historian, so YABU... that file is the only thing that can tell the story of the time you don't remember.

Sorry, I wasn't in any way saying it was wrong that they had it, I was just surprised that they had it! And surprised at how thick it was.

Thankfully I should be happy with my rather small (yet alarming) file.

And also wondering why they were asking me for 'any medical history?' when they had Chaucers Tale of Canterbury before them.

Where do you start with medical history?

It's ok when you're not in pain, but I remember a surgeon telling me off for not telling him that I had asthma and a history of PE. FFS, I'd told the other ones, how was I supposed to know you wanted my complete medical history - which I can't remember because I'm in pain and you're shouting at me.

It was just an observation. I really didn't realise they held such files. That's all. I thought you'd go to your Cardiologist and he'd have the cardiology files. I didn't realise your entire file floats about among specialities.

Well, I ask the patient for their history because a) some people are amazing historians, especially if they have a specific condition. They tend to become pretty expert at their own care. And b) it's a bit rude not to!
I will always also read any notes available because a) it'll be in medicalease and may contain info the patient may not know or think of, b) it's professional to read what another clinician has said/done/advised/diagnosed and c) patients generally cant be trusted as historians.

The reason a cardiologist may have, say, your neurology notes is that all the body systems are interconnected in so many ways. In ITU you'll have had a whole range of specialties involved in your care, conferring and working together as a team.

Basically, don't worry pet, your consultant(s) are doing right by you

Congratulations on your recovery. Multi organ failure is a big deal. You're a fighter!

@BlueSuedeStiletto You sound like a lovely doc and my consultant was too. I'm just a bit nervous about upcoming tests, so, what can I worry about? I know!!! The size of my file!

I really out-do myself sometimes with the trivialities I come up with in some daft attempt to KNOW WHAT'S WRONG'.

I'm sure you're well used to us!

For e.g., do they want to know I had a c-section? Usually no. That I have asthma? Not really (UNTIL THEY'RE A SURGEON SHOUTING AT YOU). When you guys ask 'What's your medical history - I don't know what's relevant! I suppose they have access to it - across all specialisms - so off with them! Don't be bloody asking me!

I have what they call a “significant and complex surgical history” aka a nightmare abdomen. I have all my medical history listed in the notes section on my phone. That way I don’t forget anything, and if I’m feeling too rubbish I can just pass the phone to whatever Dr I’m talking to so they can copy it down.