What do you do if want to challenge what a doctor's written about you in your notes?

What happens if when you visit your doctor, either your GP or a specialist Consultant

 and you realise that perhaps the whole thing isn't going to plan. Perhaps you're not happy with his/hers interpretation of events, or they've come up with a diagnosis your not happy with? What can you do? You may have been a patient in hospital and you're unhappy with what the doctors written in your notes. You've put in a subject access request to see part of your notes and when they arrive he or she has said something that you're in complete disagreement with - what then?

Doctors are not omnipotent; they're not always right, but if you disagree with what's been said or the diagnosis itself what can you do? Well naturally, you can put a complaint in to the hospital, most have  rigorous complaints department that will put the wheels in motion to investigate your complaint and in some cases invite you in to discuss it further with the doctor and a member of the complaints team. This of course depends on whether all parties involved are happy to do this.

But what if you want what the doctor's actually written taken off your clinical notes and off any correspondence? Or if you feel he's said something to your GP in a report on your progress and you feel it gives an inaccurate record of events.

In all likelihood the doctor's opinions will have to be left untouched, any factual information can be challenged as stated in the Act; however the Information Commissioner points out clearly that:

"The Act cannot be used to challenge a professional

opinion on the basis that it is inaccurate just because another person, even

another practitioner, may have a different opinion. If the opinion contains

factual information that is incorrect then it could be challenged. A challenge to

a factual inaccuracy or the reliability of an opinion may be recorded alongside

it, since it will usually be important to maintain the original record."

 

The doctors' professional opinion is a chronological record of events, remove any part of it and it could make it difficult to challenge should you wish to complain about your treatment at a later date. The Information Commissioner gives clear guidance for good and bad practice however:-

 

Good and Bad practice

A patient gets a copy of his medical file from his GP and disputes an opinion recorded in it. He also provides convincing evidence that it includes incorrect factual information.

Good practice

The surgery explains that it has to be kept as a true record of the doctor's professional opinion, but agrees to include the patient's comments clearly on the file. The correct factual information is recorded but a record of the error may continue to be held to explain possible unforeseen consequences.
 

 Bad practice

The surgery refuses to record the patient's objections to the opinion and only notes the factual inaccuracies.

 

So to summarise; if you feel that you're not happy what a doctor's written in your notes or correspondence regarding your care, then you have every right to challenge it. They not be able to remove it completely, but they can record your comments disputing what the doctor's written next to it.

 

 

 

 

Gillian Jones is a full time freelance copywriter, further details are available here: www.taith.net/