What is in my medical record?
Your medical record contains records from many different sources. Your prescriptions, letters we have received from hospital and those we have sent, results of blood tests and other clinical tests, vaccinations and more. It also includes the entries from professionals like GPs and Nurses.
What do you write about me?
Your medical record has been written by professionals, for use by professionals. In the context of general practice, Clinicians will make notes throughout a consultation, this can vary widely in terms of the length of an appointment, the setting (face to face vs a telephone consult) and the subject matter. A clinician may use abbreviations and paraphrase what is said rather than write long sentences verbatim and may not document something that is not said that isn’t relevant to the consultation matter. There can also be times where a clinician may document observations about a patient if relevant (i.e. appearance or behaviours) which have a bearing on the clinical matter.
A clinician may document an opinion, particularly in situations where the diagnosis is uncertain or as a diagnosis evolves and changes over time. It is important to note that although there may be different clinicians that you meet or speak to when accessing the GP surgery, we all use the same record, and what we write is often helpful for the next professional who is involved.
Members of the practice team, may also add entries to your record to record when we have given you information or advice such as contacting you to book an appointment for a health review or advising you to contact another healthcare service when we are unable to help with your query.
What if something looks wrong?
Under Article 16 of GDPR, you have the right to rectification, this means that you can request to be rectified personal data that is incorrect or misleading as to any matter of fact. Health records are special category data, considered more sensitive than other types of data. In most cases, we are unable to remove clinical entries that were incorrect, but we can add an entry to the record to make it clear that the information has subsequently been noted to be incorrect.
Toe dispute or query and entry in your medical record you can:
Use the form on our website – “Dispute or Query Online Medical Entry”
Submit a request to us in writing.
· We will not routinely discuss these requests over the phone.
· We will not rectify data such as opinions where the clinician feels this an appropriate opinion to record and was accurate at that time.
· We may decline requests which do not affect the clinical interpretation of the entry, for example “stopped smoking 10 years ago” when it was 11.
· We can also refuse requests that are manifestly unfounded or excessive.
After I make a dispute or query, what happens then?
On receipt of the online form or letter, we will write back to acknowledge receipt of said letter. We will then pass this to the clinician(s) involves who will look at this. This should take no longer than 60 days though for particularly large enquiries, if we require more time, we will write to you. We may also inform you if likely to take longer if submitted around times of expected disruption to the practice e.g. Christmas or Summer Holidays when we have high numbers of staff off on planned annual leave.
We will look at your enquiry and the record. We will then write back to you with an outcome. If you still feel there is factual inaccuracy, you may write to us further to explain your reasoning and we will consider this.
Can I speak with a GP about this at a consultation?
No.
General Practice is under unprecedented strain, and conversations about medical records, particularly if not speaking with the original clinician involved, can be time consuming and divert experienced GPs away from clinical care to deal with administrative matters. Therefore, GP appointments will not be booked routinely to deal with this, and a GP is well within their right to decline to speak with patients regarding this, should the matter be raised while in clinical consultation. It would be inappropriate to ask non-GP members of staff (i.e., asking a receptionist to change records), they will advise you they are unable to discuss this.
If a GP feels a discussion if required, they will make those arrangements directly with you or advising our receptionists.