False information on medical record

[OohShakiraShakira]

This has annoyed me but the receptionist's attitude has me wondering if I'm overreacting so I'm opening up to AIBU.

Last week I had a standard TSH blood test to check my thyroid function. I have underactive thyroid and this is checked every year to make sure my medication is working. I logged on to the app this afternoon to see my results. They were there, but there was also a separate test result for the same day for alcohol consumption. It stated that my alcohol consumption has increased from 1 unit per week in 2018 (the last time I was asked by GP how much i drink) to 2 units per week.

Except no one has asked me my alcohol consumption. To be clear, there isn't anything in my thyroid test that would indicate weekly alcohol consumption. In short, this is false information that has been added to my record. I'm assuming the surgery have been targeted with surveying patients' alcohol consumption, and someone has just made up the answer and added it to my records. I mean, if they'd asked me my consumption, I'd have happily told them, but they didn't.

This has annoyed me. It is inaccurate, it's also unethical and I'm sure must breach some kind of code of conduct?

I phoned the surgery to query it and the receptionist was very blasé and said "it would've been a pop up on the nurse's screen when she took your blood so she's updated your records." I replied "but she didn't ask me anything about alcohol consumption, so this is false information." The receptionist replied, with attitude, "so don't you drink at all then?" I replied that that is irrelevant, you can't just make up information and add it to my medical records. Receptionist replied "it's no problem, I'll just delete it then." Again in a slightly stroppy tone, as if I'm making a fuss about nothing.

I get that the increase they've put is minimal, but it is the fact they've falsified the information and added it to my record that I think is concerning. What if, for example, I'd told my life insurance that I'm teetotal and then i dropped dead. This misinformation on my record would be enough for them to not pay out on my policy.

Anyway, the receptionist was so nonchalant that I don't know if I'm overreacting.

So, aibu?

I'd be putting something in writing. The receptionist should not and cannot deal with this.

I have recently had something similar. The GP I had seen had confused me with someone else and added their info to my record. I wouldn’t have seen it if I’d not checked NHS app. I made a formal complaint to the surgery and my complaint was upheld. Whatever that actually means! I wonder how often it happens

Is there nothing on the app under the GP Health Record section because mine lists all sorts from my last health check of who updated what on their records. Have a look on there first to see.

The biggest GP system suppliers (TTP and EMIS) would absolutely have a record of who updated the system.

There could well be a financial incentive for gathering information on alcohol consumption, it could be part of that it may be separate. I would put in a complaint to the practice manager and go from there.

I don’t think there are any drinks that are 1 unit? Unless you do 1 shot a week?

Likely you said you have 1 drink a week (in 2018). Most drinks (cider, lager, wine) are 2-3units each, and someone has later corrected the units.

That's not really the point, is it? She might be drinking 10 pints if Stella a week, but nobody actually asked her, and has instead made up an answer, which is absolutely not OK when it's medical records.

OP, I'm always slightly amused when I have a pill check, and my notes will say things like "discussed importance of checking breasts" even though she did no such thing. I'm assuming it's an automated checklist and just ticks them all.

That's not the point though. It's the false information, not how much I do or don't drink.

From memory, when previously asked in 2018, I told the gp that i do drink but infrequently and not heavily, maybe a glass or 2 of wine if i go out for dinner once or twice a month. We agreed to put 1 unit per week as I believe the measure was consumption per week, and it would be untrue to say zero.

How is the receptionist, a nobody on 11 pounds with no medical degree , able to casually converse with disrespect to you and being authorised to delete things. That is bonkers. People in this country are slowly being enslaved and are happily sleeping

My medical records are pretty much a work of fiction. Of my three pregnancies, only one is on my record. I have also been assessed, without reference to me, as being 'mildly frail', which I most certainly am not. I have tried to get things changed, but they saying cannot be done. They can apparently put a note on by way of correction, but eight years later I am still waiting. It's poor.

I would suggest downloading the NHS app and checking all the records you can

I did this out of boredom when we were all prompted to download it due to covid passes etc. Found out 80% of my records are inaccurate, dates wrong, and worryingly, there's a entry on mine saying I drank to excess whilst pregnant.

This was put on my record by a GP I made a formal complaint regarding, as he gave me the wring medication. The meds he gave me were for depression caused by alcoholism, he assumed I drank as I was 25 and according to him "everyone my age does". I didn't, I had two under 2, one with severe illness. I didn't have time to drink.

To justify this behaviour, he wrote that on my record- I wasn't even under that surgery whilst pregnant.

I argued to have it removed. It could've been incredibly damaging.

I’ve had this issue recently. I kept getting calls and texts from my surgery to remind me that I need a diabetes check due to my gestational diabetes history.

I never had gestational diabetes, and it’s 22 years since I last gave birth! Each time I got a message I would call the surgery and let them know these facts and each time they’d make a note. I suggested they had another Rachie1973 on the books, but no, apparently mix ups can’t happen.

It came to a head in April when I got an ‘URGENT. We need you to contact us regarding an important health matter’. Well I suffer health anxiety so I panicked. God knows why, but I just did lol.

Called surgery. Bloody gestational diabetes thing again! This time receptionist says to me ‘only way to stop this is to have a general check up with bloods, I’ll book you in’. I’m like huh? Check my records, only thing I’ve been to surgery for in 3 years is my severe health anxiety!!! Apparently though, people lie and I could be excluded from my surgery if I didn’t do this….

Took bull by horns, went along. Had bloods, discovered no diabetes, but high blood pressure, so ECG etc. Dealt with l, that, quite chuffed at myself for doing it.

Went to pharmacy to pick up prescription. Our pharmacy is within the surgery so is done immediately. At desk I was asked name and date of birth. ‘Oh they don’t match’. Gave address…. Different Rachie1973 had been allocated MY prescription! Sorted it out, moaned about it, left.

2 weeks later. Text message ‘our records show you had gestational diabetes……’

ARGHHHHH

Ah so you were asked in 2018.
1 175ml glass wine is 2 units.
If you have 1-2 small glasses, 1-2x a month that is a range of 2 units to 8 units a month, with an average of 5 units a month.

So 1 unit a week would be closest, although look pretty odd.

If it’s a 250ml glass, that is 3 units and the range would 3 to 12 units a month, so more like 2 units a week (if rounded).

I think it’s just a minor clerical error where someone was recalculating the units based on the information you gave but using the 250ml for a glass of wine instead of the 175ml measure.

I think it’s a bit OTT to say it’s ’falsified“ information when it’s plain to me that what you reported could be plausibly calculated to get to both 1 or 2 units a week in your records.

What if, for example, I'd told my life insurance that I'm teetotal and then i dropped dead. This misinformation on my record would be enough for them to not pay out on my policy.

But you aren’t teetotal and you did tell your GP that you occasionally have 1-2 glasses of wine, 1-2x a month.

I don’t think 2 units a week instead of 1 unit a week of alcohol in an NHS record would invalidate any life insurance whatsoever if you dropped dead. Both are so far below the recommended limit of 14 units per week, that it’s not even going to register as an issue.

Yeah it is a PITA that it went from 1 to 2 units a week and you asked as is your right to have it put back to 1 unit. Errors happen all the time, it is very rare for someone to have intentionally falsified things. I feel you are catastrophising a bit, and you haven’t suffered any damage.

Think of the 22,000 or so NHS patients that die every year due to medication errors. Your records error was harmless. It’s more important for them to get the life or death stuff correct than ensuring your record stays at 1 unit a week vs 2 units a week.

People wasting time over nonsense like this is one of the reasons the NHS is failing. We really need to start charging for GP services .

I’d be fuming too. I have also had a complaint about my treatment- I had a test carried out that may have resulted in me having an operation. Before even giving me the results the doctor who requested the test sent my results to a surgeon (who I didn’t like and wasn’t going to see again) without sending them to me first! I have now got the awkwardness of telling that surgeon I don’t want surgery- I actually want to discuss surgery with a different surgeon. And I work for the NHS 😡

Oh yes, because it’s outrageously entitled to expect important medical records to be accurate, akin to asking for the moon on a stick. And expecting medical professionals to muster the basic accuracy your average year 4 would be capable of will bring the NHS to its knees, so we should react dramatically, and this it not an OTT reaction at all 🙄

You think the doctor wrote down, word for word, the explanation OP gave about her drinking all those years ago rather than, as OP said, simply putting down 1 unit a week, and then recently, someone went through all the records, reading all the notes and recalculating anything that had been mentioned in a narrative form?

If this were what GPs' surgeries were doing, it would be no surprise it's so difficult to get an appointment in many places. But it's not. The Dr. is unlikely to have written down the narrative, just entered the units as they agreed with OP. And I hope to god no one is going through patients notes recalculating the alcohol units from the narrative text written years ago in order to try and make their records accurate. That would be a crazy thing to do.

Quite! @SpiritAdder 's explanation was nonsensical.

Yes, I think SpiritAdder is either trolling or pathologically contrary.

How do you know which surgeon the GP sends test results to? How do you get to choose? All I’ve ever been able to do is select where I want to go for a hospital consultation.

I'm down as smoking for 50 years, and I'm only 58! Bizarro GP asked how much I smoke, said 20 a day for 25 years. He said a standard 'day' is 10 a day, so that needed to be doubled and recorded as 50 years of smoking.

I saw a consultant for something else looked at me funny and asked what age I'd started smoking. He corrected the record.

@Rachie1973 @NorthernDancer and @WillimNot I'm honestly so shocked that your records have such serious discrepancies. That is outrageous compared to my minor issue.

My medical records are also wrong on the subject of births- I had 4 c-sections but my record only mentions 3. I thought it was really strange and couldn’t understand it.

I don't think I agree with you that it's rare for staff to falsify information deliberately. I think it's very rare that it's done maliciously, but I think there is a lot of "updating" where they are supposed to have asked the patient but don't (I assume because of time constraints and because patients get sick of answering the questions which often don't seem to relate to the reason they're seeking care). And through this quite a bit of false information is recorded.

There is a pop up box on the electronic form that you plug in the # of drinks and tick the type of drink and then the IT calculates the units.

Whatever gave you the idea it would be handwritten notes?

That info would still be there on the system.

Not really, it is raw blossom assuming that GP notes in 2018 were handwritten that was nonsensical.