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?

She goes silent if I mention it won’t talk at all. I remember as we both lived at home at the time , are very close in age so it wouldn’t have seemed wrong in any way with the dob they gave. The descriptions and dates etc are when dsis was at her worst with it all. I remember my mother crying a lot worrying it would affect dsis in the future and I think that’s why she did it ? I’ve tired to get a confession by text but she won’t enter into a conversation about it . Dsis now denies she ever self harmed and when I tried to talk to her about it just laughed .

This is relevant for anyone who has incorrect information in their records (medical or otherwise)

https://ico.org.uk/for-organisations/uk-gdpr-guidance-and-resources/individual-rights/individual-rights/right-to-rectification/

(You also have a right to request a copy of any records of your personal data held by an organisation - you do a Subject Access Request. However some exemptions to their obligation to disclose do apply)

Actually it could have been your GP that was correct on that one (although the figures you give aren't quite right, but you can have a smoking history of 50 years at 58 years old and not have started smoking at 8 years old.

In standard documentation regards smoking there's a figure called "pack-years". It's essentially the number of packs you smoke a day, multiplied by the years you smoked them. So if you'd smoked 2 packs a day for 25 years, you smoking exposure would be 50 pack years.

https://www.mdcalc.com/calc/10187/pack-years-calculator

The consultant of

I also have a lot of vaccines recorded that I’ve never had (travel ones from years and years ago ??) but that’s the least of my worries when it comes to my records

My GP surgery added to my son's notes that he had attended A and E and because it could be a non accidental injury, a section whatever the number was had been sent to Social Services.

Except he had not attended A and E. At all, in the previous three years. He'd not had any reason to, let alone a non accidental injury.

I wrote to the Practice Manager about it. It transpired the admin staff had coded the entry wrong, eg they'd meant to put in a code 1 (referral at my request to speech and language therapy because he is disabled) but had instead entered it as a eg code 2, non accidental A and E visit. The manager was apologetic and said it was all ok now because there were no open complaints at Social Service about our family. But it does make you think...if I hadn't looked at his notes because I'd just signed up to the NHS app, I would never have known and that would have stayed in his files!

My record said I chewed 1.68 KG of chewing tobacco a day!
I've never tried chewing tobacco, and have no clue what a 'normal' amount would be per day, but even I think this amount might be considered excessive, if not impossible to chew in 24hrs! 🙄
I finally worked out that it was the date I'd stopped smoking regular, cigarettes 20yrs ago. At my next GP visit, I brought up the false record. He queried me several times 'are you sure you never used that much?' etc. Pointed out the date 16/AUG/2002 and the error. He finally changed it.

Write to the practice manager and/or speak to you GP at the next visit.

I can't see how having a single blood test would stop them contacting you about the gestational diabetes in the future - I had GD and have to have a fasting blood test every year (at one point it was a glucose tolerance test, but they've changed that now), so they'll keep asking unless you do manage to get it off your record. On the plus side, did it qualify you for an earlier covid vaccine?

There's not going to be some big conspiracy to falsify alcohol records to get extra pennies, if there was and this was a purposeful lie then obvious simple thing to do would be to select that you still drank 1 unit/week, why change the amount?! Or they could simply have ticked the menu box to hide the change/entry from your view.

Anything that attracts a kind of payment will collect more information and require logging of far more information than units/week i.e. do you think drinking is a problem, do you drink everyday/most days, has anyone ever commented on your drinking, have you ever tried to cut down.

It'll really be something daft like an accidental click/software change. When updating your records with the TSH/other levels it'll likely in the background draw down your alcohol consumption since alcohol use affects overall thyroid function. It could just as easily be an update to the software and it now only allows even numbers/minimum of 2, or someone was manually copying it across and mis-read or mistyped a 2.

Receptionists/admin team are trained to keep medical records upto date and make changes routinely. i.e they will update new information from hospitals/the discharge letters etc, medication changes... If you phone and request a prescription/repeat they enter that for authorisation by a prescriber. It's a normal part of their job.

I honestly wouldn't waste anymore time or thought on this one.

But it was false information in the first place when you agreed, so that's no difference to it being false information now. It's just a different wrong number.

Hold on @SleepyRich let’s back up here a second

Or they could simply have ticked the menu box to hide the change/entry from your view.

You’re saying that the surgery has an option to hide entries in medical records from patients?

Of course we do. It's just a check box next to the data entry. It's no secret.

As standard I don't personally use it very often but it's quite necessary for clinicians to be able to document what they feel they need to and have the option of restricting the patient from seeing it - there could be any number of reasons for this - could just be that they don't want you finding out you've got some awful diagnosis in a very blunt medicalised report via the app instead of in a face to face appointment, or perhaps we have concerns a pt is being abused by their partner/or they've confided they're being abused - it wouldn't be uncommon for the abuser to have access to our patients phone/be checking up what was discussed in medical appointments so you'd hide it to protect the patient. Also it's for my safety as well - some patients aren't nice/prone to aggression - I need to be able to document accurately without having to omit facts that could cause a violent break down in relationship at next appointment or with the reception team...

As standard I don't believe many use it often but of course the option is there.

This explains how it's down/gives safeguarding as an example:

www.google.com/search?q=systmone+hide+entry+from+patient&oq=systmone+hide+entry+from+patient&gs_lcrp=EgZjaHJvbWUyBggAEEUYOTIHCAEQIRigATIHCAIQIRigATIHCAMQIRigATIHCAQQIRifBTIHCAUQIRifBTIHCAYQIRifBTIHCAcQIRifBTIHCAgQIRifBdIBCDcxMzBqMWo0qAIAsAIB&sourceid=chrome&ie=UTF-8#fpstate=ive&vld=cid:a02f4eb0,vid:F32mLNitaYU,st:53

I don’t care what the justification is, it is absolutely appalling that a person’s medical records can contain information not shared with them. Presumably this can all be obtained via a Subject Access Data Request?

Not necessarily.

There are exemptions to the duty to disclose.

Of course you could appeal any refusal and then the ICO would be the ultimate arbiter.

Or a court I guess, if you then appealed the ICO decision.

It seems bizarre there would even be an option for one unit a week? That's literally half a pint. You'd think it would be in increments like 1-2, 3-4, 5+ etc. but yeah, that isn't the point as they didn't actually ask you. It's good she changed it but they should have explained how it happened.
If their recording system meant one unit was now marked as two then they should tell you.
I would be asking the practice manager for an explanation.

"I would be asking the practice manager for an explanation."

I can see there's never going to be unity on this one. And absolutely I whilst I agree that if anyone spots a meaningful error in their records absolutely they can/should ask for it to be corrected, but demanding an explanation from the practice manager on this?!?!

You'll just sound like a crazy conspiracy theorist shouting about how "big GP is making millions making up lies by rounding up my estimated alcohol consumption to 2 when really it's only 1".... it's nuts.

I'm going to goto bed sharing a more amusing correction I heard made against me from a pt last week (fortunately it was amusing to the patient too):

When documenting a common short hand for patient is pt. I write this quite a lot - dry cough - normal for pt. for example.

The software at my surgery scans text as you type in an attempt to add in diagnostic codes which can then be used in the behind the scenes database searches etc. I.e. If I start writing otitis externa - as I get to otitis.. it might will auto text an option for "otitis externa (F1234)" and I can just click it or press return and it'll place that code in your record. Unfortunately, for some ungodly reason writing pt. and the pressing return will code something along the lines of - "pt denies having intercourse with sex worker abroad (F5678)". She got a bit of a shock when she noted that on her record. Simple to remove fortunately - right click "mark in error" and it's gone.

It's a proper pain, you;re often fighting against the clock so typing notes in one box but reading something else where at the same time and it's easy to miss when the system adds in codes like this.

For something this trivial I wouldn't really care but if it was something else I would complain.

I thought I was unusual in having a constant fight over inaccurate medical records and I’m horrified I’m not. I’m even more horrified that they can choose to hide whatever they feel like, when they can put in so much rubbish (by accident or not it doesn’t change the harm it could do). This is appalling.