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?

It's surprisingly common sadly. At my last annual diabetic check, the "nurse" just took my blood pressure and took a blood sample. Usually, they check my feet, take my weight, ask questionnaires etc. I looked on my record and they'd "made up" my weight and noted that they'd checked my feet, and had "copied and pasted" the questionnaire answers from the previous year. It had been a 20 minute "consultation" and I was in for less than 5 minutes. Not as if she'd been running late either as I went in bang on time and when I came out, no one else was in the waiting room so she wasn't rushed off her feet. I let it go that time, but if it happens next time, I'll be writing to the practice manager!

We've got similar with DH who reported pain in his right thigh to his oncologist and when we saw the letter she'd sent to the GP, she'd noted it down as the left shin!

There's no attention to detail and often it really matters!

I had this experience, I haven’t drank alcohol for 10 plus years just don’t like it. A few times on my record they have put occasional alcohol drink x units per week, they never asked me at all. My questionnaire when i joined the practice said 0 units a week.

I emailed and asked them to correct my medical notes

Why did you automatically assume it was ‘shady’? Stop being dramatic. The notes are for health professionals and not you - maybe she added previous stats?
Maybe she made a mistake. Just contact the practice rather than stirring up a negative discourse about GP’s and the NHS.

I suspect she made those observations up.
Practice nurse.

Exactly!

It’s nothing to do with throwing shade on the NHS or GPs, you are extrapolating. The NHS has good and bad practitioners, let’s be honest. If the GPs don’t want patients to see notes they shouldn’t publicise them.

Or as shown by numerous posters on this thread it’s possible that they get it wrong and being able to see notes means you the patient can hold them accountable.

I suspect she did as well. I don’t know where they came from. She’s recorded my HR as 77 but the only time I’ve had it taken has been in hospital. I hate hospitals and it’s always super high when I’m in. The last time they almost wouldn’t discharge me because it wouldn’t get below 100.

Well I wouldn’t say it’s “nothing to do with throwing shade…”

read your own op

To quote… you

AIBU to think this is quite shady?

Yes throwing shade on this particular GP not all gps or the NHS in general.

I’ve been shocked recently by my gp notes, so many inaccuracies. I had a MH referral that was full of totally wrong info stating I was receiving therapy (I was rejected) and that I’d requested meds privately and been rejected. I hadn’t.
Today I had a private psych appointment and she asked me about my WLI as the GP had told her I was receiving them privately - I’m not and never have! Totally bizarre.

I would email so it is in writing that you dispute the documentation.

I was offered a flu vaccine at the pharmacy - turns out I actually didn't qualify by age that year - checked my notes last Autumn, just inquisitive - the (visiting) pharmacist had entered a serious heart condition on my notes. I have never 🤞 had any heart problems.
Both pharmacy and GP said only the person who entered it could amend it! I was a bit pissed off (thinking of holiday/life insurance, other meds etc).
Checked again a while back, and it's gone.

But why even “throw shade” on this one GP when surely the most reasonable explanation is that either it’s an error or she just automatically populated with last figures because she forgot. Not great… but to complain? Nah. Just pick it up with reception on Monday that it wasn’t taken. The end

It was an error
the doctor was advised as such
the doctor removed the error

@Tepidwater are you a gp? Or medical professional? Wondering why you’re so defensive when even GPs have come on this thread to say it’s inexcusable.

@Tepidwater are you a gp? Or medical professional? Wondering why you’re so defensive when even GPs have come on this thread to say it’s inexcusable.

Observations are extremely important and can identify things like indications of serious infection, sepsis, cardiac problems etc. Deliberately writing made up obs is malpractice and taken seriously. Falsifying records is malpractice and taken seriously. There simply is no excuse.

Not at all

but I guess you and I just go about life in very different ways
I simply wouldn’t think this was shady
id think… oh I’ll give reception a buzz on Monday so my record in updated
the end

You see I wouldn’t presume deliberate in the first instance 🤷‍♀️

It says it is different from her normal BP

So do I (retired nurse). They're too.......textbook normal.

You're not a healthcare professional then 😂

If only people knew what goes on 🙄

My BP has been taken in hospital the last few times and has been all over the place, high and low because I’ve had surgery. So whatever is added doesn’t match any I’ve had recently.

It’s also the way the notes are as I’ve explained it says ‘examined patient, obs t, HR, BP,’ then goes on to say my abdomen is soft and no kidney pain. To me that reads like she’s taken them at the time but she hasn’t.

Monitoring your BP is important if you have kidney/ureter/bladder issues, as the kidneys regulate blood pressure, and temperature and pulse measurements can indicate infection.
it is unacceptable that these observations have been omitted from the examination or entered incorrectly for whatever reason. You have a right to rectification - contact your practice manager.