Thursday, October 20, 2005

Keeping your own medical notes

I just saw a patient from the UK, who was complaining bitterly about the NHS. She had been referred to a consultant, who spent 15 minutes talking to her; and then dictated a note about his medical recommendations to her GP. When she met her GP 6 months later, the GP showed her the note - and there was absolutely no resemblance between what the consultant had told her verbally; and what he had written in the note. Unfortunately, the only record available of the consultation was the consultant's note, so she was forced to just fume silently. This is why it's a good idea to make a note of the your version of the consultation and the doctor's recommendations, and keep this as part of your medical record. If you want, you can send a copy of this to your consultant, so he can amend it if he feels the need to. This is the best way of making medical records more accurate - and more patient friendly !
What I do in my own practise , at the end of the consultation, is to read out what I have written ( my writing can be quite illegible !) to the patient. This allows me to to confirm that my recording of their medical history is correct; and that they have understood the plan of action.

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