DISCOVER THE HIDDEN SECRETS OF YOUR MEDICAL RECORDS

Your patient notes used to be a mystery to everyone outside of the health professions, and their contents were a closely secret. As a patient of a GP or a hospital Consultant you’re now legally entitled to learn your notes in full. Here are the best way's to obtain access to your patient details; and how to learn and understand them:
1. Ask permission to get access to your notes - and you’ll get to see them quicker and easier. A GP or hospital Consultant is the legal protector of the contents of your patient notes and member of the public who wishes to learn them must first obtain permission in writing from that legal protector. Write a polite letter to your GP or hospital management requesting permission to access your notes. Include your full name, full address, date of birth and your patient number (if known). It is helpful to state the reason why you want to view your records and ask for a response within two weeks as some practices and hospitals will not give priority to this request and will not deal promptly with them unless they have been given a deadline.
2. When you understand how your notes are organised you will know how to learn them properly. The organisation of patient notes can be very confusing but patient notes usually consist of four different sections. One: your essential details - name, address etc; visits to or by your GP; past and present medications prescribed to you; previous referrals to hospital; out-patient clinic appointments; operation details and dates; details of any care you have received at home by community nurses. Two: treatment details for each of your visits to your GP or hospital - information about the reason for your visit; how your illness was managed; and the medications given and/or operations carried out. Three: letters - copies of communications between healthcare workers such as GPs and hospital Consultants regarding your past and present care; including referral letters from your GP to a Consultant and discharge letters from a hospital to your GP. Four: investigations - a full record of blood tests, X-rays and scans, and full reports from the heath departments involved.
3. It is best to take a witness with you when you visit the practice or the hospital as this will protect you in case notes go missing later on. Typical: you will usually have a member of the practice or hospital staff sitting with you as you learn your notes - to ensure that you do not tamper with or remove any of them. It is vital to ask your partner or a trusted friend or relative to sit in as well - this covers you against the possibility of a complaint by the GP or the hospital management. Case: if some of your notes are subsequently mislaid, you’ll find it easier to prove that this was unrelated to your visit.
4. Always assay that you've been given the correct notes before reading them as this will avoid potential confusion and even alarm. Why: there may be more than one patient with the same name as yourself at that practice or hospital; Smith, Jones and Patel are very common names. Case: at present, there are ten ‘David Jones’ living in the town of Guildford in Surrey - a source of confusion if one of them asks for his mediacal records at the nearby hospital. How: assay that the cover of the notes has your correct name, date of birth and address and double-assay that each page of the contents has your details on it - notes are sometimes re-filed into other files in error.
5. Have a plan of action - so that you can learn your notes quickly and easily. Helpful: before reading, be clear about the exact information that you want to obtain from these medical records. Case: you may have had a growth removed from your bladder and want to see if the explanation given to you by the hospital Consultant matched the information detailed in Consultant - GP correspondence. It is useful to write down a list of questions that you want answered on a piece of paper; then tick off each question as you find out what you want to know. Vital: if in doubt, ask. Typical: medics are renowned for their illegible handwriting and for using abbreviations. Case: FBC means full blood count; a routine, basic blood test used to screen for such disorders as anaemia, infection and blood clotting abnormalities. Other common abbreviations include:
ac - ante cibum; before food
AXR - abdominal X-ray; an investigation carried out if you have had abdominal pain
BP - blood pressure
Ca - carcinoma
CI - contraindications
CNS - central nervous system
CSF - cerebal spinal fluid
CT - computerised tomography; a scan similar to an X-ray to visualise internel organs
CVP - central venous pressure; an indication of cardiac health
CVS - cardiovascular system; comprising the heart and blood vessels
CXR - chest X-ray
DM - diabetes mellitus
D&V - diarrhoea and vomitting
DVT - deep vein thrombosis; a blood clot typically in a vein in the lower leg
ECG - electrocardiograph; a means of monitoring cardiac health with a tracing of its electrical activity
ENT - ear, nose, throat
GB - gall bladder
GI - gastrointestinal
GU - genito-urinary; the reproductive and urinary systems
Hb - haemoglobin; a basic blood test, typically for anaemia
IM - intramuscular; for case, injections into a muscle
IV - intavenous; as an case, injections into a vein
JVP - jugular venous pressure; another sign of cardiac health
LFT - liver fumction test; blood test carried out to assess the health of the liver
MSU - midstream urine; the least contaminated urine, used to test for kidney infections, for case
nbm - nil by mouth; before an operation
NSAID - non-steroidal anti-inflammatory drug used for pain and to reduce inflammation
PO - per orum; by mouth
PR - per rectum; rectal examination
SC - subcutaneous; for case, injections given into the tissue just below the skin
SE - side effects; of a drug
T - temperature
TPR - temperature, pulse and respirations; basic observations of a patient’s condition, after an operation, for case
U&E - basic blood test to screen for the abnormality of the natural chemicals in the blood; abnormal levels of potassium and sodium can contribute to ill health
URTI - upper respiratory tract infection; laryngitis, for case
UTI - urinary tract infection; an infection of the kidney or bladder for case
Note: a medical dictionary is essential if your notes are likely to be extensive and/or complicated. Recommended: The Oxford Concise Medical Dictionary (Oxford University Press) - it’s used by the professionals and provides clear, understandable definitions.
6. Make notes about your records - this way you’ll have a permanent, written record of them. Unfortunate: although you have a legal right to learn your patient notes, you are not allowed to remove any of their contents, write coments on or deface them in any way. Motto: look but don’t touch. Hint: take in a pen and paper to write notes for future reference about what you’ve learn - document times, dates, which medical professionals were responsible for your treatments, investigations etc.
7. Stay calm - so that you avoid being rushed. Fact: medics are busy people and may want to speed you through as quickly as possible. but you have the right to take as long as you wish. Admonish: if you wish to make a complaint about the management or treatment of an illness, put it in writing on an official basis. Don’t: complain verbally there and then. Reason: the best way to get the desired results from any future official action you may take is to be methodical; this increases your chances of receiving co-operation from within the medical profession.