How would I go about questioning the contents of my medical notes?

Question

A recent stay in hospital led me to gain possession of my medical notes, on looking through them I found that I apparantly had Kawasaki's disease as a child, I asked my mother about this and she knew nothing about it.
After looking it up I have found that it is a potentially serious childhood illness that someone would be hospitilised for, my mother insists I have never had this disease let alone spent more than an afternoon in any hospital as a child!
I wasn't too bothered about it but she has pointed out that if there is this kind of error in my notes what else could they have got wrong? does anyone know how I can go about investigating this further?

toxicsgrl- I have no idea who you are love, but thanks for your weirdness, it was the highlight of my morning-from the miserable cow.

And before anyone suggests it, I am not looking to sue or anything like that, I just don't want things recorded in my medical history that aren't true.

IAINTELLEN- I repeat, I am not looking for compensation, there is nothing to be compensated for, I just want to find out how to get it removed,

Answer 1

Medical notes can't be altered. What you can do is arrange for you and your mother to supply an entry for addition to your notes explaining that you do not feel these entries are correct. I have had something similar come up once in a patient's practice notes.

Answer 2

Are you worried that you have Kawasaki Disease, and haven't been treated? Kawasaki Disease doesn't just go away. Untreated, it can effect the heart. Is your mother aware of you ever needing intravenous medication, or having to bring you back to the hospital or clinic for several days in a row? Is she aware of you ever having the symptoms of Kawasaki's? They're pretty obvious, and most parents would have sought medical attention. Have you received regular physicals for school, and work? Has any doctor ever told you about a problem with your heart? Have you yourself ever suffered from symptoms that could be related to your heart?

Seeing a disease listed in your medical history, that you know you didn't have, could purely be a mistaken entry. You could hire a lawyer. They employ people whose job it is to go through people medical record with a fine-toothed comb. They were probably employed in the medical field at one time, and can spot any errors. They may be able to find that the mistake was made during your recent stay, or 20 years ago by an office clerk who's now 75 years old.

If you're asking because you're thinking about a potential law suit, you have to prove you were somehow harmed. You can question whether medical treatment you received in your past may have been different, as in, less effective, more expensive, or more extensive, because the people who treated you believed you had Kawasaki's. Then it falls back on who to blame for putting it in your history. Not the person who paid attention to it when treating you If you never had it, never were treated for it, and have never been treated differently because the entry exists, you don't have a case. The person who made the mistake may be reprimanded. Errors don't make law suits. Something has to physically harm you.

None of those things is going to remove the entry from your chart. As far as that goes, you can contact the hospital and inform them of the error. They can include another entry correcting the information. You can also inform your doctor, and he can do the same. If you are admitted to another hospital, you can inform they that you're aware of a potential mistake in your history. Then they'll disregard it, and note the new information.

Answer 3

I think your first port of call should be to see your GP. Surely the hospital would have had to send him/her a copy of their findings.

If this is the case, speak with your GP about what else they found, and the ramifications of you having been diagnosed with a specific condition and not being told about it.

Also, if it turns out that you do have Kawasaki disease, ask why you haven't been offered treatment. (I'm presuming here that you're not taking medication that might have been prescribed to combat Kawasaki disease. Having said that, I know only too well that doctors do sometimes prescribe medication without explaining why, or what it's for. My own brother was prescribed an anti-epileptic drug for years without being told that he had epilepsy. I know a little bit about some medications and asked my brother to question his GP as to why he was being prescribed it.)

If your GP hasn't received notification about any such diagnosis, I would suggest that you approach the consultant/doctor at the hospital where you were treated for an explanation. Even if s/he has left the hospital, they should have your hospital notes, or a copy of them, so another doctor can explain to you how the diagnosis was made, and why no treatment options were offered.

If it turns out that a mistake has been made ... and that's not unheard of ... I suggest that you approach a solicitor to send the hospital a letter, requesting that their records be adjusted to show the true cause of your hospitalisation.

It's up to you as to whether you should get your solicitor to consider suing the hospital/doctor for undue anxiety caused by your finding out that you had been diagnosed with a potentially long term condition. Do be aware, however, that untreated Kawasaki patients do often overcome the acute symptoms. Some patients do go on to develop coronary vasculitis (inflammation of of the wall of blood vessels including veins (phlebitis), arteries (arteritis) and capillaries due to leukocyte migration and resultant damage).

In knowing this, echocardiograms should be offered to check for resultant progression of cardiac involvement.

I'm sure that you've probably already gained the information that you sought when you researched the condition on the internet, but I've listed the main pages that I looked at.

I wish you the best of luck.

Answer 4

You just have to write to the hospital records department to ask for access to your notes. There isn't usually a problem.

Just be aware that doctors do have the right to withhold notes from you if they believe seeing them would be more injurious to your overall well being. I've never heard of this outside of mental health services though.

As far as questioning what's in them, I doubt that would be a problem, but I don't think you'll get very far with changing the contents of your file. Maybe the simple answer is if you are ever asked your medical history (say you have to go to A&E), just point out that although your records may state that you had Kawasaki disease, you didn't as far as your family know.

Answer 5

Not going to give a long answer about legal issues etc, as there are plenty already. Just a quick suggestion. Why not ask to be tested for the disease or the appropriate antibodies. That way you will know if you have had it and been treated, or if it is still active. If you have no antibodies then you have never been in contact with or had this illness, so you will have grounds to have your records amended.

Good luck, Mel.

Answer 6

You should definately get this fixed it could cause problems with health and life insurance latter on... Try making an appointment with your doctor to go through your notes.

Answer 7

Can't think of anything constructive in answer to your question, hotgirl, but I'm just coming on here to comment on toxicsgrl's "answer".
Who rattled your cage? Go take a chill pill.

Answer 8

You have full rights to your records. Just ask for them and get a second opinion.

Answer 9

error in notes?
is there error in treatment?
it seems that you are OK, treatment brought more benefits than dammages

Answer 10

you have a motor bike disease? and your avatar is ridiculous. this is one ofthe things that drives me mad. you look like a miserable cow. slag me off all you want, at least i'm brave enought to have my real pic