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?

@SpiritAdder I can't quite understand how you are so spectacularly missing the point.

Obviously nobody revisited a 2018 conversation, the receptionist pretty much confirmed that it would have been a pop up question at her last visit but OP wasn't actually asked.

Complain to the Practice manager by email. It's well known that many mistakes happen on medical records. all they can do is put a note on, they are unable to delete anything.

Ah, yes one of our lovely care navigators who definitely never give out incorrect information to patients.

By written down, I was assuming typing it in rather than handwriting. I don't expect anyone to hand write anything nowadays and haven't done since the last century! Sorry if my language was confusing.

Nevertheless, you think the doctor recorded the drinks OP said in some way and used the system to calculate it as 1 unit. Then, years later, someone went in and entered it all again into the popup calculator, but putting in the drinks slightly differently and accepting the new calculation?

Because that would also be nuts.

Except that a record showing 1 vs 2 units of alcohol drunk a week is blindingly not important. It’s a minor clerical error at most.

I had an issue when I had DC1, I saw the doctor's notes which said I smoked during pregnancy, I have never ever smoked but said to the midwife I was concerned as I sat near someone at work who smoked during the pregnancy, big difference. I was so cross and asked them to remove it but they said I would need to raise a formal complaint, I was so tired after having a baby and was worried sick about DC1 jaundice and difficulties breastfeeding I never did so it is probably still on my notes.

Although I have an ex-friend who is a complete alcoholic, she went to the GP who asked how much she was drinking and she said one bottle of wine a night, she was outraged the GP wrote two bottles a night, although that was nearer the truth but not that close to what she actually drank. She'd come over for a cup of coffee and drink four bottles of wine and that was fairly standard in the end we fell out because socialising with her became so boring not to mention expensive!

A mysterious addition to my medical records occurred a while ago. When going for a routine check up the nurse offered another test based on my having had diabetes in pregnancy. I told her this was not correct and was met with disbelief. Really had to push to get the info removed

My surgery has me recorded as an e-vaper. I am staunchly anti-smoking and vaping. I haven't got round to asking for this to be sorted

It often depends on how it's recorded. E.g. some systems will just have a box you can input units, some will record drinks, some will have a box that has a range.

The difference between 1 and 2 units is negligle. No one ever tells the truth anyway or has the ability to accurately say how many units they drink. No one is ever going to look at your records and use that 2 units.

It could have an impact in terms of medical or life insurance.

For example, in 2018 you said you maid 1 unit per week. 2020 stopped drinking. 2024 took out a policy and put on the application for that you don't consume alcohol. Make a claim for some reason and your medical records state that in 2024 you told your GP that you DO drink alcohol.

A bit far fetched in this scenario is 2 units is unlikely to be an issue but in principle there could be other scenarios where it is an issue.
A medical professional making up information on an official record cos they CBA asking is wrong on so many levels

HCPs are happy to type any old tripe if it suits them, in my experience.

My DD had recurring UTIs and the GPs always issued different prescriptions and often asked me which one I thought she should be prescribed next as a prophylactic (? wtf how would I know? I don't have a medical degree?). Anyway, for those unaware an antibiotic prophylactic is where you just take one pill out of the packet a day over several months, so you kind of end up inadvertently stockpiling the pills because of how they are prescribed.

Anyway, as a result, we had boxes and boxes of different UTI antibiotics at home in my DD's (and all in date) one time we went to see the nurse practitioner as she had a new UTI.

The nurse practitioner said that she was going to prescribe an antibotic and I said AND I QUOTE "we have lots of nitrofurantoin at home because she has been prescribed a lot of it, and it's all still in date so I am just checking if you want to issue another prescription as we have that at home.

Anyway, nurse insisted we get yet more of the stuff, I thought no more of it.

The UTI escalated and we ended up in A and E - not because it was an emergency but because my surgery since covid won't see children in pain.

Sitting there in A and E and I can see the Dr's screen because he's making no attempt to hide it at me,

Nurse practitioner has written notes from our visit that say:

"Mum is very keen to give her child antibiotics she has at home leftover from when Mum herself had a urine infection".

I've never in my life had a urine infection.

Dickhead.

I don't think a non medical person can amend gp medical information. I think once a medical person writes something it's written as evidence which can be presented to their governing body or a court so it would need someone quite high up to challenge them.

If it were me I would do a freedom of information request to the practice manager and then arrange for a meeting with the practice manager to discuss your formal complaint following the details you receive.

If you have a reasonable relationship with the GP and they've likely clicked on the wrong drop down box, this could be addressed by emailing the practice manager no?

They may not have had to enter it all again, depends on the exact system exactly what was saved.

Too, to get to 1 unit, that involves rounding down. Another possibility could even have been a system update that rounds up instead of rounding down, meaning no one entered anything.

IT caused errors are a huge problem.

Regardless, it’s a minor error.

Op could this be a mistake ... last time at checking in for my dd doctor appointment (asthma review) the little computer that we use to check in asked me if dd was a smoker ... I wasn't expecting this and pressed the yes button by accident and spent the next ten minutes at reception telling them to get this corrected ... reception lady was like dont worry it means nothing and won't have anything to do with dd care.. i was like erm I'm worried if this will reflect badly on me as a mum actually 🤣🤣🤣🤣 I can't have anyone thinking my child smokes. She doesn't by the way .. 🤣🤣

I agree the difference between 1 unit and 2 is negligible. However, just because she drank one (or 2 units) per week in 2018 doesn't mean that should be re-recorded (and presumably date stamped) on the system as still being accurate in 2024, without at least checking there have been no changes.

What if she's now on 40'units per week?

@inthemid that's terrible!

With it being a child, have they been referred to enurisis? Having so many infections must be so hard on both of you, I do hope you got to the root cause.

There are just other more likely possible causes for this error than a nurse deliberately falsifying a medical record.

https://www.bbc.com/news/articles/c4nn0vl2e78o

Was years ago. She outgrew it eventually, which is what all the consultant urologists (including the private one we paid for) said would happen.

Point of my post being, wtf was this nurse insinuating I give random leftover adult medication to my kid?

I’ve posted before about this - I have self harm on my records and I’ve never self harmed . I only found out as applied for life insurance and they wrote to the gp .

it was my sister who self harmed on those occasions it appears my mother gave MY details each time they went to a and e. There’s nothing I can do. I begged the gp to even look at my arms etc to show I have no scarring. They just told me ‘it’s nothing to be ashamed of’ which I know but I’ve never self harmed . All they’d agree to do was add my letter explaining all of the above.

The OP’s point, quite rightly, is that nobody should be making stuff up and adding it to people’s records. And if there has been a genuine error, where actual real information has been gathered properly from a patient and recorded against the wrong person, this should be corrected. Furthermore, the practice should collect stats on how many errors it makes and review them periodically, to assess whether changes in procedure are required.

Like PPs, my records are also a work of fiction. a few years ago I was cc’d into a referral to gynaecology and at the top of the letter, in bold, it stated I had a mental disorder I don’t have and have never suffered from. in any case I have no idea what relevance it was to a gynaecology referral. I contacted the surgery to complain and they did apologise for the mix up, but it was too late by then.

Another entry states I was admitted to hospital with alcohol intoxication which wasn’t the case at all. I’d collapsed in the street and because it was a Friday night they just assumed. No wonder the nurses treated me like shit when I came to. This one really upset me but I don’t have the energy to attempt to sort it out.

There are other things but not quite on this scale. Like when I saw a consultant about an allergy issue which affects me every day without fail, they’ll state that I am ‘occasionally affected’ in the clinic letter.

I changed my name and the GP receptionist refused to accept it! It was my legal name! I obviously came back in when the paperwork I received (e.g. referral letter or prescription) wasn't in the right LEGAL name and complained to a different receptionist who changed it immediately. But not 'allowing' me to have the correct name on my records could have been really dangerous. It's frustrating when patients aren't listened to because it's harder to give the right care when you don't know whether the person has an alcohol/thyroid/blood sugar problem because the information the patient gave isn't recorded accurately. Mostly it's accidental but there are incidences on this thread of deliberate malicious recording.

Gosh, what a pain. Did your mother ever explain why she gave your details?

Hope your sister is OK now.

@OohShakiraShakira you are right this is serious. Putting incorrect information in your records is a type of data breach. You can report it as such (follow the procedures on the doctors website) and make a complaint if they don't respond

That is shocking.