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?

This can happen.
Just quietly query if either the practice manager.

I agree but they’re often the the only way to get the antibiotics I need so it’s especially frustrating when I’m given the standard 3 days of nitrofurantoin which doesn’t cut it!

It's strange because my GP on the 2nd appointment of the day last week wrote in my notes I declined a chaperone for vaginal exam in actual fact I wasn't offered one ! I didn't even think about that at the time , I just wanted it over and done with ! I read the notes on the app !!! Is this something I should query or just leave it ? I'm not fussed but I don't like the fact it said I declined when I did no such thing !

I've had this it definitely happens

Sounds like an error just called them?

This can absolutely happen, it’s happened to me twice recently. Once on a visit with an AP (who sent me straight to A&E) my notes said obs were all taken but in error not recorded but all in normal ranges. No obs were taken as she was in a rush to get me out of there, I was ok with that

the second time was my yearly review with the practice nurse. She was shocking, very rushed and had me out in there in less than 10 mins. After reading the notes she’d added a load of things she was supposed to have talked to me about but didn’t

the worse one is that she’d had a very long and frank conversation about my eye test that was overdue (my fault) and went into great detail about what she said. She never mentioned it once!

obviously the notes reminded me and I booked the test in straight away. I was annoyed she’d added this imaginary conversation into my notes

Oh and she also said despite being told of the risks I refused all help to try and quit smoking. I’ve never smoked in my life. I’m going to get the smoker flag and comment removed on my next visit

A three day course of antibiotics given out by a pharmacist may suit some but it won't even touch the sides for someone with a complicated, or set in UTI.

Don’t be ridiculous. If an error has been made, it needs correcting.

@Nexttomee OP, I’m a hospital consultant of almost 30 years. Of course you need to point this out. Medical records need to be accurate. If you did not have these tests done then they should not have been recorded. Perhaps it was an error, perhaps it was something else. Either way it needs addressing and amending as soon as possible.

If your blood pressure suddenly rose today, it would be important to compare it to an accurate baseline for example.

I am extremely passionate about people raising mistakes in the NHS and addressing them. I do not get defensive of my profession, as people’s lives are literally at risk. We need to have the highest possible standards of governance and there is nothing wrong with you reporting this. Indeed, if it leads to a change in practice for the better, that will be safer for everyone.

No. This is only for an uncomplicated urinary infection. If I had a UTI, and then had another one in three months‘ time, the pharmacist would not be able to give me an antibiotic even for that. It’s only for managing straightforward cases.

I would absolutely flag this!
Its basically arse covering because they forgot to offer or couldn't be bothered.
What if they did the same to someone who really wanted one like a younger girl or victim of SA. It could even be a way to cover up SA by the doctor. Please flag this to the practice manager!

I've had the same albeit it was a physio in a GP practice noting they had offered chaperone for a physical examination. I looked at the NHS app as soon as I got home and saw it said that. I wasn't bothered that I hadn't been offered one, I was actually surprised one would be offered for the shoulder examination but I was a bit perturbed to see she had written that she offered when she certainly hadn't

Is there a way to contact in writing? Our GP practice use Blinx, it is predominantly for medical or admin (like fit notes) queries, but you can send anything really.

I’ve used it a couple of times when I’ve spotted errors in consultation write-ups like this. The handy thing is, being in writing, you obviously have that written record. Could be useful if it impacted travel insurance, just for an e.g. Our practice do always correct the consultation notes though.

Definitely report it and get it corrected.
I received a copy letter from a hospital appointment.
It contained a number of errors regarding my condition, including comments that were not said during the appointment.
It had been sent to the wrong GP practice. One I have never been registered to and nowhere near my home address. I have not moved or changed practice in years.
I had to spend nearly an hour on the phone and then confirm by email what my correct details were. No idea how this ridiculous error occured.

OP, get it corrected. I saw a GP and when I looked at his notes a few weeks later he said we had discussed my thyroid- we hadn’t, he said he gave me a prescription- he didn’t and he also said that he had advised me about pre-diabetes- he hadn’t! When I contacted the surgery the GP called me back and admitted he didn’t know why the notes were incorrect but he thought he had given me a prescription for meds that I had previously had many years before and not taken for about 3 years!

Surely the antibiotics you received will have the name of them on the box??? In addition, why not just drop your sample off with Reception like everyone else does?
Just ring the practice and point out the error in your notes. It’s a simple as that.

Given your update around a long medical history could it be that you were seen in a hospital recently and they took your obs and she copied them in to your notes?

100% report to the practice manager. Making untrue notes could have fatal consequences for the wrong patient.

Because when I called the gp their triage system allocated me this doctor, who then said she wanted to examine me? So I couldn’t really just drop the sample off ‘like everyone else does’. I presume she wanted the obs because I have a stent in my ureter at the moment and an infection can easily turn into sepsis. Although she didn’t actually do them!

I check the antibiotic because in the past I’ve been prescribed 3 days of nitro sometimes for an upper UTI and had to ask for something else. The prescriptions automatically get sent to the pharmacy.

Maybe but isn’t that a bit daft for temperate and blood pressure because they can fluctuate? The last time I was in hospital was about 5 weeks ago.

People need to stop defending this. You can’t just copy down the blood pressure from a previous date unless you specifically state the date it was taken on.

We have moved away from the time thankfully when doctors were God and could not be challenged. For those of us that strive for high standards of ethics and governance, it makes me furious when colleagues do not follow guidelines of accuracy and transparency.

Again, the posters on here who were recorded as having refused a chaperone when they were not even offered one, I’m outraged by that. Definitely raise it please.

Nope it's not .If you're under a hospital team for urology you can ask for self start antibiotics and then just drop in your urine sample .

I’m a GP and we would definitely want to hear about this as it could be a probity (honesty/ integrity) issue, or it could be a mistake. Either way it needs to be addressed with the trainee by their trainer to avoid it happening in future. Please do feedback to the practice about this. An email would be fine.

My mum had something very similar happen to her, for a very similar issue!! She had details of heart rate, blood pressure and temperature in the notes following a visit and none were taken. She called the practice and they said my mum must have got it wrong and she had forgotten the gp doing the tests. When mum protested they suggested her age was a factor - she is 73!! She has subsequently changed practices. A different surgery did the exact same thing to my grandma - they blamed her dementia when I called to ask them to correct something, but because of her dementia I went to the appointment with her….

I think that is harsh to say ‘a lot of GPs lack a lot of knowledge’. They are generalists so I expect them to know common illnesses, like chest infections, in depth, and know enough about everything else to understand when to refer or seek specialist advice.

I have ME/CFS and my GP knows next to nothing about it - but I think that is understandable because she has me and one other patient with it and there is no treatment for it anyway. However, I still find her very kind, empathetic and helpful.