Viewing hospital notes - acouple of probably v silly questions

[nuttygirl]

I'm going to the hospital today to view the notes relating to giving birth in April. I have already had a response to my complaint letter and I'm reasonably satisfied with it BUT there are a couple of issues

1 - they have the time of my internal exam wrong
2 - they say there was a discussion about my options for pain relief (there wasn't, I was only offered pethidine)

So what I want to know is, will my vaginal exams be called vaginal exam on the notes or will they use a medical term/abbreviation? Similarly, what should I look for to see whether my notes say pain relief options were discussed?

Is there anything else I should be looking for also?

Your vaginal exam will probably be down as EPV (examination per vagina) and I would imagine it will say something along the lines of 'pain relief options discussed' which is suitably vague to mean anything! Unfortunately notes are often assumed to be gospel no matter how the woman's memory differs and no matter how many witnesses there are who know that something is inaccurate.

Are you seeing them alone or will there be a midwife/doctor there to 'translate'?

Try to remember that you can only see what's actually recorded and if they haven't written it down at the time then it won't be there, such is the nature of having a human write stuff down in the middle of a busy labour.

Vaginal exams are likely to be written down as VE. Who are you going to see to view your notes? Will it be a cons clinic you are going to or are you meeting someone from PALS?

Beware that handwriting can be shocking, so it will be hard for you to decipher without someone to translate!

Ask about everything and go through the notes from beginning to end so that you don't miss anything. And make sure that you actually get to see them, it's no use cons or someone else holding them across the other side of a table so that you can't see.

And while you're there ask them to photocopy them for you to take a copy away with you to peruse at your leisure. You're entitled to have a copy. It's the law.

Dp and I are convinced that my waters breaking was recorded wrong because we recall it happening around 10 and it was noted as 8.30, so have to assume that mw went back to write up notes after the event and got it wrong. It happens. Not great.

BTW when it comes to childbirth, there's no such thing as a sily question! So always ASK if you're ever unsure of anything, better than not knowing!

I'm just going to the Access to Health Records dept. so there won't be anyone there. I am hoping to get a debriefing session. They said in the response to my complaint they don't offer it but if I was to insist then they'd provide a debriefing session (but didn't tellme how to go about it) so I'm viewing my notes first and getting photocopies of anything I feel necessary before I request the debrief.

I know the time of my exam is wrong because my waters broke at 11pm and they examined me when I first got to the hospital at about midnight. They said I could go home if I wanted at 1am but I stayed (feeling sick) and had a bath right away. I was in the bath until they agreed to give me pethidine and was not examined until after the pethidine had been given and I said I was ready to push. (about 2.15-2.30am)

They say I was examined at 01.25 am (at which time I was in the bath!). I think it's possibly an error (i.e. letter should say 12.25 which would be more accurate)

Thanks for the advice btw

photocopy the whole lot!

I've gone over my notes time and again and I nearly always find something I hadn't noticed before. And when I found somethign that really shocked me I called Cons secretary and got an appt to see him to go over notes.

Insist on a debrief, you are entitled.

Thanks, I'll get the whole lot copied then. Might be back later with more questions!!!

Hi Nuttygirl
sometimes it can be several hours later when the midwife gets round to writing up the notes if she has been busy, so it relies a lot on her memory in this case.
As Klaw rightly said... 'copy the lot'. If you did this, have a look at the drug chart, thats the most accurate place for recording the time of the peth, as most m/ws will sign this at the time of giving a drug.
As for the VE, the partogram is probably more accurate than the notes. The partogram is your 'at a glance' record of progress in labour, and VEs are usually documented in this. Usually the notes are written later while the partogram is kept up to date as labour progresses.
Discussion of pain relief can be written quite crypically as something like 'd/w pt re analgsia' meaning discussion with patient regarding pain relief or something like that. That discussion is unlikely to be documented in full, and may only have comprised of a question like ' do you want pethidine or an epidural?'
Ultimately, its all down to how much time the midwife has spent writing, and the more time that she has her face in the notes, the less time she will have to support you in labour.

Good luck and sorry to be a bit long winded.

Just out of interest - what do you need to do if you want a copy of your notes?

Hope you find out everything you need to know nuttygirl

XXX

Just ring your hospital and ask to speak to the medical records department. I did it recently and they sent me the necessary forms. It might cost - mine was £10.

Sooo... Nutty, how did it go?

Nuttygirl?

Sorry, meant to post before now but baby kept needing fed/changed/played with/...

I got my notes, the woman forgot to charge me for photocopying (she was too busy cooing over the baby!).

Discovered that the mw has written the time at which she wrote each section of notes and has put what has happened up to that point. That's why the letter says my exam was at 1.25am, cos that's when she made the note relating to it (along with everything that had happened over the previous 1.5hrs)

It also mentions a discussion re pain relief but doesn't say what was discussed.

Just had one question about them...from the time I started to push there's notes saying about the baby's heartrate. How do they know what it was...AFAIK they didn't monitor it (but I maybe just don't remember.

Also writing is v difficult to read.

Re monitoring of the baby's heartrate - this can be done very discreetly with the sonicaid and I must say I barely noticed it as the sound was turned down and I was very much in my own little world. I hope the notes help explain things.