AIBU GP made up observations in my notes

[Nexttomee]

I saw my gp yesterday for a UTI. She examined me and sent me to do a urine sample. When I got home I checked my notes on the NHS app and saw she had added a blood pressure, heart rate and temperature, but she definitely didn’t take these. She must have made them up as I know I would remember having my blood pressure checked. The number is added isn’t what my usual bp is.

AIBU to think this is quite shady? She was a trainee gp. I’m not sure why she felt she needed to make them up when she could have just not written anything?

Surely it's more likely that she added them to the wrong patient record rather than made them up. Give your surgery a call.

Write a letter asking for a correction.

I'd question it nicely - it's possible she's put someone else's stats onto your record by mistake.

I’d definitely report that. Could be a mistake, could be someone not coping with the job and it would be good to have it flagged over something non dangerous.

Get that sorted straight away as it’s a bad error. I’d agree that it is likely to be the details of another patient but it’s not ok!

YABU to immediately assume she made it up.
It's far more likely to be a mistake. As others have said, contact your surgery. to sort it out.

I’m not sure if it is details of another patient as it’s in the middle of a long note, if that makes sense? I have a complicated medical history. Kind of says ‘examined patient, blah blah, t 36.9 hr 77 bp 120/77’ then carries on with our discussion yesterday.

Still raise it with the practice manager.

I had a UTi recently and the nurse has written that I was complaining of stinging when I pass urine. No I didn’t, that wasn’t a symptom at all. DD has Leo noticed things in her notes that she never said or didn’t happen.

Whole thing sounds odd as most GP practices don't give out urgenct appointments for UTIs, which can be treated by your local pharmacy if you are female aged 16-64. At our surgery, you would be asked to provide a urine sample only, no appointment.

https://www.england.nhs.uk/primary-care/pharmacy/pharmacy-services/pharmacy-first

I’m definitely with you OP. I suspect she was told to check obs but forgot. Far too coincidental that your BP is your normal BP. I’d definitely raise it with the practice manager but expect them to cover it up.

Goodness you must spend you life actively seeking out shadows @Nexttomee

must be a depressing

I don’t have a normal urinary tract I have a lot of issues with my bladder and ureters which is why I see a gp for UTIs so they can send my sample to be cultured, and also why I check my notes as I wanted to see which antibiotics had been given.

Was she aPA or a GP?

A lot of notes are by AI these days. Every time I see a consultant they use AI to write up the consultation.

just email

I’m actually intrigued as to how often this happens tbh. The GP was reading notes from the hospital to my father and it was full of inaccuracies. Things he’s supposed to of said but most definitely didn’t. Definitely contact practice manager and flag it.

A gp trainee. The AP at my gp surgery are amazing I always trust them!

This isn’t true - but I have spent the last year of my life with catheters, ureteric stents and kidney problems after a botched hysterectomy - so perhaps I’m a little bit less trusting of the NHS than most. I’ve realised a lot of gps can lack knowledge about complicated UTIs and sometimes I have had to advocate hard to get the treatment I need eg a longer course of antibiotics than the standard 3 days, which is standard for a complicated catheter associated UTI. That is why I checked the notes.

not really related to the post but you have my sympathies. Women who haven’t experienced having had complicated/ prolonged/ repeated UTIs across their adulthood don’t necessarily appreciate how difficult they are and how hard it is to get medical professionals to take them seriously.

When you add an ob the previous results also show so she could have just copied it from a previous result of yours if she forgot. As an HCP I would encourage you to query it with the practice manager

A lot of GPs lack a lot of knowledge! If you have any kind of illness I find you are the one educating the GP during the appt 🫠

I suppose they are just generalists at the end of the day but it doesn't inspire confidence 🙈

I kind of see them as glorified pharmacists now.

Making up fake notes is a striking off offence for obvious reasons. It is dangerous and also speaks to dishonesty. What if op's blood pressure or temperature was very elevated at the appointment but that got missed because of the fake records?

Like others have said, I wonder if the gp used AI to write the notes and it automatically inserted previous numbers on op's record and the trainee didn't notice. It's actually got worrying implications if this practice becomes widespread. I would suggest phoning reception or submitting a form and asking for it to be corrected.

Accurate record keeping is a GMC requirement.

Hopefully it was a mistake but it is one to highlight as failing to keep accurate records is negligent.

If she did it deliberately that's actually very serious as patient records need to be accurate for good reason. For your own health reasons primarily, particularly where you have a longstanding issue that they are trying to resolve as those key readings give an impression of your health and what else is going on in your body. Another reason is that records can be used in court proceedings and the court generally assumes the record is accurate.

Flag it as a mistake to the surgery. Lots of reasons that it could have happened but they are all fixable.

An AP is usually a nurse with specialist tracing so good at what they do . A PA ( physicians assistant ) is a poorly trained ‘GP substitute ‘ with no medical degree just a masters . I actively avoid the one at my GP practice after they lied about examining me and I ended up in A&E