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?

I mean it's gone, fair enough, but the GP surgery was adamant that they couldn't remove it (spoke to an actual doctor, not someone on the desk).
My thought was that the pharmacist needed to put a reason for me qualifying for the jab. If that happened, it is malpractice, and could have had repercussions for future meds/insurance (I have a condition for which I need to take daily meds). If I hadn't looked and asked about it, it would probably still be on my notes.
So it's gone, fair enough, and I won't mention it again, but I did take it seriously, and I think I was correct to do so. The actual regular pharmacist was really shocked.

Every GP surgery in the country can choose to operate slightly differently, it’s absolutely possible that a trainee GP would see patients with UTI’s as part of their training. With regards to your post OP I really don’t get it. Mumsnet is not the place to ask. Contact the surgery and politely ask that this be reviewed by a clinician and make it clear that you did not offer the information recorded. They can then investigate and determine if a) they made something up because they forgot or b) recorded it incorrectly in your records. Making comments about making it up is not particularly helpful when you have no facts to base this on, but you are absolutely right to want it corrected and investigated so that the surgery can use this for the purposes of establishing if the trainee requires additional monitoring for example. No it’s not acceptable but they should be afforded the opportunity to look into and rectify before it being plastered online.

What did they do to examine you?

I'm just wondering if they could have checked your pulse / resp rate whilst doing a more general examination? Only takes 15 seconds or so of feeling your pulse.

Either way, worth asking the practice to try to get some clarity

They felt my abdomen and back

Insurance
16 years
charity
6 years

only the person who entered it could amend it! I was a bit pissed off (

they contacted the person who entered it. Who then amended it.

Yes, probably. But I don't fully understand your wish to downplay this and other such occurrences in this thread. I'm not one to make mountains out of molehills, but a diagnosis of heart disease has implications for the meds I take and the condition they treat.

Because in your case you were pissed off that…

You told your GP to amend your records
Yhey told you only the person who made the record can amend
you later saw it had been amended. So the GP contacted the pharmacy and the pharmacist duly rectified the error.

So all fine. So I can’t think why you’d be pissed at this and use it as an example. An error was made. The person who the error… rectified it

Because it shouldn’t have been made in the first place, and because it potentially had serious implications on the persons life? Surely you can understand why someone would be annoyed at that and want it taken seriously?

Oh human error is poor for sure

No, OP is right. Adding things that didn't happen is serious. Previous results are pointless in this situation. I've trained GPs for many years. This needs bringing to the attention of the GP trainer in the practice. It could be that this GP is struggling or needing extra support but what has happened isn't right. The OP has a complex urology problem if she has a stent. They were actually correct to bring her in and examine her ....im not in favour of online or phone management of complex urinary problems. A practice near us had a patient die with a stent and sepsis. Urology tried to blame the practice but they had done everything right. I'm with the OP 100% here. OP write to the practice manager and afk the letter to be given to the GP responsible for training. They should look into this.

What @Nexttomee said above, and also the fact that if I hadn't looked*, the record would still be wrong! Simple to understand really 🤷

(*it wasn't something I would normally do - but it absolutely is now!)

There are some shortcut keys which then add standard advice but clearly not the observations. I’d bring it up, OP.

I check my notes every time I see the GP and I have any inaccuracies corrected. I was diagnosed with cancer a long time ago and my critical illness cover nearly didn’t pay out because one of my notes was noted “social smoker” instead of “ex social smoker”. There was a diagnosis placed on my records recently which I have the minor form of - this would have affected my travel insurance. Check everything and get it corrected.

I’ve had so many completely wrong things in consultant letters, and the worst was when a GP wrote that he’d done an internal examination - including observations - when he absolutely had not!

I’ve learned you MUST challenge all of this - it can really come back to bite you. I was injured in a car accident in 2017 and due to the GP’s inaccurate reporting I almost didn’t get compensation. And they won’t change it if you leave it too long before challenging.

So do I. Hospital consultant.

What was even the point of your post? Why pick at the op, trying to make out she’s lying about having an appointment?

I think some posters think because something is the case for them, that anyone whose experience is different must be a liar!

As I’ve alluded to my ureters were damaged in a hysterectomy a while ago and since then I am almost always examined by a gp when I have a suspected UTI, because I have a much higher risk of sepsis as a result of catheters, stents and kidney damage. That’s why my current obs (temp, heart rate and blood pressure) are important, not obs from previous visits to the gp.

So the issue is not so much asking the gp surgery to correct the notes with updated obs but to understand why they weren’t taken yet it was implied that they were.

Again. I see that poster saying that the situation sounds “odd” based on her knowledge and experience.

Your response is to see that poster calling you a “liar” and basically stupid because doesn’t realise that her own experience isn’t the same as everyone else’s

Any update op - did you raise it with the surgery?

Yes I did - but I haven’t had a response yet besides an automated one - only an update to say the gp also forgot to send off my urine sample for culture. Luckily the antibiotic they gave me seems to have cleared it up.

Mine keeps writing absolute bullshit in my notes. Driving me mad.