Annoyed consultant lied on my notes today

[Ivortheengine8]

I went for my 22 week check up today with the consultant. My appointment was an hour late and obviously they were busy.

When it came to me, I had my BP checked and urine, Dr asked if everything was ok and that was it - No problem. But when I read through the notes later on I noticed she had written under fetal heart 'FHH Sonicaid'
She did not listen to the heartbeat at all, so why lie and write it in my notes?

Would you be annoyed or am I overreacting?

Could the Consultant have written that because she thought the MW had already done it? At our Consultant Antenatal clinic, the MW takes you into the room & carries out the "basic" checks - wee, fetal heartbeat, BP, measuring tummy etc. & then the Consultant comes in a few minutes later when they have finished. I could imagine that if your clinic runs similarly the Consultant may have assumed the checks had been done?

It still doesn't make it right as clearly she should have asked before writing that on your notes but I can see how the mistake might be made .

Emma I don't see a midwife. Straight in to the consultant. I think I saw the midwife at my very first appointment that was all. :)

I had a similiar experience Ivor. At one of my earlier appointments, I saw a student midwife and he was clearly very nervous. He attempted to find the babies heartbeat with the doppler, but could not pick it up. He fumbled around for about 5 minutes and then out of nowhere just declared 'Ah, there we are' and quickly removed it from my belly. It was VERY awkward, because I looked at him and he knew that I was fully aware he had not found it! Thank goodness I could feel baby moving around inside, otherwise I think it would have sent me into a spin! I then noticed that when he reported the heart rate, he just used the same figures that had been reported at my last appointment.

I was not angry, but quite concerned about it, so did bring up the issue (very diplomatically) with my regular midwife. IMO, they really shouldn't be so blase about such things.

If it were me, I would most definitely say something- you can bring it up in a polite manner. How will they know these things are occurring and take steps to rectify them if noone reports them?

I've had experience of this as well, but with midwives after the birth. I've noticed in my notes that they had apparently checked my legs (presumably for signs of dvt) and palpated abdomen when they had done no such thing. I didn't think much of it at the time, but it's obviously something they should have been doing, but couldn't be bothered. I would mention it, as suggested make out you don't know what it meant.

Have had similar after birth too. Was supposedly given celexin (?) injections on day one which came as a bl**dy big shock to me when someone came at my tummy with the 'second' dose on day 2! l also missed a few rounds of pain meds which aparently I'd 'had' (they were very interuppted on rounds) Thankfully I'd packed my own! I never had my loss checked after my last nd my baby never saw the paediatrician til she was 3 days old either as they thought she'd already been seen.
Question everthing you are not happy with!!!

Apricot what did your midwife say about it? Was she pleased/agitated you told her?
Chynah, I am also on clexane at the moment (low dose), but Obviously if its a therapeutic dose it is very important to get it right so that's quite scary! :(
Deleting as with above they are things which have potentially serious outcomes.

I would mention it, and not try to act like you don't know what it means. They are YOUR notes and you have every right to be treated properly! Why pretend you don't understand, when you obviously do, and expect the right treatment. Don't be afraid. The consultant was cutting corners and cutting corners can come back and bite you on the bum at anytime. Better she/he is dealt with now, before they neglect another more serious patient and cause something bad to happen to them or their baby.

Tell you midwife and have this consultant sorted out now for your sake and the sake of other patients in their care.

I was thinking about it again this pm (gosh I should just leave it alone!! But I actually feel a bit insulted, especially after having found the fundal height thing too. I am not a Dr myself and have no first hand experience but my father is and so are two of my Bother in laws, so I am not totally oblivious to what goes on. I am actually going to ring my dad (although he is retired now and is probably not up to date with what goes on now) and see what he thinks.
Maybe she did make a mistake but that means two mistakes in a matter of about 5 minutes

Hmm. Maybe she did make a "mistake", but the whole reason for having notes with your name and date of birth on is to try and make sure that "mistakes" don't happen.

She has written and, if they're anything like mine, signed or initialed to say that she has performed 2 checks that she did not perform. She has written down a measurement that she did not take. In plain English, she has falsified your notes.

In the event that something goes wrong, with any patient, the notes are the only documented evidence of the care that was provided. Those notes could, potentially, wind up in a court to demonstrate that the consultant did (or didn't) do everything she was meant to do. I know the NHS works hard to try and make sure that there are checks and balances in place to ensure that "mistakes" (such as not giving medicine to the right patient, if at all - at what happened to you Chynah and deleting).

At the least, the consultant needs a kick up the backside to be more careful when filling in records. If this is a regular occurrence with different HCPs then the hospital should consider what procedures they can put in place to make it harder for "mistakes" like this to happen. Neither is possible if no-one tells them "mistakes" are being made.

(Sorry - you may have guessed that I'm struggling to see this is a pair of pure and simple mistakes or confusion after a busy clinic. How can you fill in the notes for a woman sitting right in front of you and write down a measurement that you never took? Or if its that easy to do, wouldn't you take a pad of post-it notes to the couch with the woman's name on and write the numbers down as you took them? Even if it was a genuine mistake, unless you let the hospital know the consultant in question won't be aware that she has areas of her practice that need improving.)

Tangle, It's good to hear your opinion (I guess you are in the field)
There are not actually any initials beside it but I know last time the midwives always did this.
I know Dr's are not God's and it is inevitable that they will make mistakes from time to time, they are only human but I don't honestly believe this was a mistake. I think she just wanted to get me out as quickly as possible. I was the last patient and they were running very late.
The Dr in question had quite a thick foreign accent (possibly Indian) and although beside the point again, I had to make an effort to understand. I don't think this has anything to do with it, but I had been sat in the maternity unit for nearly and hour and a half after my slot with a toddler (who was thankfully asleep by the time we got in to see her) and I was frustrated and fed up too but got no 'sorry we were running late' which I might have appreciated.
I'm just on a rant now!!

Sorry 'Drs are not Gods' They might be God's though!

Sorry 'Drs are not Gods' They might be God's though!

Being a cynic and having a literal turn of mind, to me that begs the questions "God's what?"

Sorry

No - I'm not in the field. But I have opted to be informed so that I can force the consultants to allow me to make my own decisions, and I expect HCPs to meet the professional standards their professional bodies hold them to. We also used IMs for both previous pregnancies and have had a chance to talk in depth about how antenatal and labour notes have been called into hearings when MWs have been sued - and therefore just what a big deal those notes are.

Rant away - its very theraputic :o

Actually I need to take my own advice and complain about a consultant I saw previously. A point that she made seemed odd and didn't fit with other information I could find, so I wrote to query it (very politely) - and the reply she sent completely contradicted her initial information. Like you say, consultants are human and can make mistakes, but she made no apology or even referred to the fact she was now backtracking like mad. Which leaves me feeling as though she doesn't see it as a problem that she misled me originally, and I no longer feel I can't trust her to tell me the truth in a consultation environment and I no longer wish her to be involved in my care unless in an emergency situation. Grrr!

Oh - and I'm on clexane as well. Isn't it fun

I wasn't sure if you were religious or not! Don't worry, nothing weird!
I think one of the problems is that today patients are so much more informed about medical issues because of the internet and I'm not sure if our Dr's take this into account. I think people know and understand a lot more about their conditions and it must be a challenge to medical professionals if they do consider it.
I know how you feel though, you lose respect for them don't you? which leads to a lack of trust. But then I think the same happens in other professions such as teaching etc.
Clexane is not fun but I have got used to it and I'm not sure if its the excess fat or the lower dose that now it hardly stings (it used to sting me a lot :()

Sorry just being nosy, but why are you on Clexane? There seems to be a few of us on here.

I was only given it post CS (both times) - one jab in the tummy each day I was in hospital. So not really on it (stingy stuff though!).

Talking to DH about the trust thing, his conclusion was that consultants are practicing more defensively as patients are less prepared to take personal responsibility and are more likely to sue if results are sub-optimal. Given obstetrics is in the top 2 (IIRC) for law suits, it doesn't surprise me that they take a very conservative approach - and with, seemingly, many women not wanting to be involved in making decisions (to prevent taking responsibility) a more dictatorial approach goes down better with the majority of the women under their care. Whether that's true or not, of course, is another question entirely - and it still doesn't excuse misrepresenting the truth. At least, not to me!

I'm on clexane as I've a clotting anomaly, identified during testing after multiple pregnancy loss. I might have to eat more chocolate to see if that helps it to stop the stinging!

Thats interesting Tangle and I'm sure very true. I think it's quite sad how the Dr - patient relationship has changed. Partly because different Dr's are seen at appointments and partly with how the NHS has changed. I don't know my 'Dr' as such. I see a different one every time and they ask me the same questions about my health time and time again! I think the paperwork they have to do is also a burden.
The other thing is that I don't think Patients have respect for Dr's anymore like they used to. (I think it's the same with other professions too) I was just brought up in a very traditional way so we learnt to 'listen' to our elders and those in charge, I don't think that is true of today's society. But in the same way there are many Dr's who take a more 'dressed down' approach.
.....Ok I'm just rambling now!

One of the posts above reminded me of one of my checks when I was seen by a student Dr. He prodded, poked and pushed at me for ages and then said very worridly (is that a word?) "Sorry - but I don't seem to be able to find a head...." To which I replied "Well, she had one last week.." MW found it no problem and passed him the thing to listen to heart beat with. Again he poked and prodded and then proudly announced all was fine - til the MW told him that that was the umbilical cord not the heartbeat....

Back to the OP though - defintely get your notes changed - if (god forbid) anything was to go wrong, your notes are meant to be an accurate recording of your care.

LOL Gin! At least the midwife was there to help him out!

Maybe you should ask a MW to come to your consultant appointments

a student one?

I haven't read the whole thread properly OP, but as a trained doctor myself, (who has worked in extremely stressful and busy situations in understaffed hospitals in South Africa) I can assure you that this is NOT a mistake. You have to report this. If notes are made during a consultation with a patient it is almost impossible to be confused about simple things like whether you did/did not listen to the heart beat.

This is a lie. One which is dome to cover her arse.

The whole point of notes are to serve as a true and accurate record of what occurred during a consultation to facilitate communication between hcps but also to remind a particular doctor of the previous consultation they had with the patient as it is very difficult to keep individuals separate when you see hundreds of patients in a week.

Please, please, please complain. This is fraudulent practise.

Thankyou RealMBJ
Need to hear it from the Dr's mouth!

Could you also clarify about the fundal height......

My dad (now retired and hasn't practised for a while, obviously trained many years ago) said that some Dr's/midwives get used to doing the FH without a tape measure and that they could have a good 'guess' so wasn;t bothered about that one much.
Is that still true of today though, surely it's not that accurate?

Many thanks

That is a little more difficult.did she feel for fundal height at all? If so does it definitely say 21cm and not 21 weeks?

Correct practise is to measure fundal height from the symphysis with a measuring tape and record the cm, however, less accurate 'guess-timations' are common particularly when there isn't any real concern for the foetal growth. It is not ideal practise but I wouldn't call it fraudulent.

Ivory - measuring with a tape measure isn't accurate. Research has shown that 5 different midwives can come up with 5 different measurements for the same woman. But guidelines do say that a tape measure should be used. I do think an experienced midwife will know by palpation if a baby is too big or small, or at least know enough to think they want to check with a tape measure.