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Thread: What constitutes meddling of medical/patient records?

  1. #1

    What constitutes meddling of medical/patient records?

    Without getting too personal i want some clarification as to what may be considered tampering of medical/patient records from say a GP surgery?

    As an example if something was left out that is blatantly relevant to a tribunal.

    If someones original patient record stated 'Mr smith goes out twice a week only with support from family' and a later report that was requested directly by the tribunal only stated 'Mr smith goes out twice a week' omitting with support,don't you think this is tampering?

    Just curious...

  2. #2
    I have absolutely no idea, but a very interesting question nevertheless.
    Hopefully some one will along to give you an answer soon.
    Call me Mike.

  3. #3
    Senior Member nukecad's Avatar
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    Jun 2014
    West Cumbria (Lake District)
    If the original record has been altered/changed/destroyed that would be tampering, unless there is good reason for the change.

    And there could be many good reasons for a change, including the patient requesting it.

    But if it's an inaccurate report of the original record then it's not tampering with the original, it's either an error or deliberate misrepresentation.

    If it's an error or misrepresentation then you show the tribunal, or whoever is interested, a true copy of the original.
    I don't know everything. - But I'm good at searching for, and finding, stuff.

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  4. #4
    I think when most people think of tampering, they ( I ) tend to think of notes being altered to show/not show something has been prescribed or given. maybe change/add dates of patient visits and what have you.
    I always thought that in a factual report, they could only state that which they'd personally observed. it's very useful to know they can add other things as per patients request, I didn't know that.

  5. #5
    Thanks for the replies folk.

    Might as well spill out all the details,a tribunal requested my GP surgery to submit my medical records,upon receiving a copy that was also sent to the tribunal i noticed something had been omitted which was of absolute importance to the tune of the example i given in my first post.

    I happen to hold a copy of an old set of notes that i submitted with my original pip claim which was dated about a year prior,when i called and asked them why this particular line had been removed first she told me there was nothing else written (lying) when i pushed her and told her i held a copy of an old report after 4-5 tries and some silence she admitted the new report is different to the old one but didn't know why...

    Pushing this particular women who apparently wrote out/printed the report some more she stated she didn't include things which she thought were 'doctors opinion' , you can see how this is going...

    Everything in the multi-paged report was the same as the year old one expect for the part which stated i needed support to leave the home

    Taking something out which is obviously important to a pip claim,knowing full well why the patient record was being asked for,the only conclusion i can come to is that this is a malicious attempt to mislead the tribunal/Judge ,not sure if this is a new tactic by DWP behind the scenes or this is just an issue with the particular people at my surgery but i refuse to put up with this bullying abuse and will be bumping this thread with FULL PERSONAL DETAILS unless i get this sorted out properly,just in case anyone is reading this...

    I was told i can make a complaint to my GP and was given another number and lo and behold the same women answered the other number,when she stated she was even somewhere else! I refuse to now deal with my GP surgery and if making public their misdeeds is the only way then so be it.

    The whole ordeal greatly stressed and made my anxiety much worse,of all places where you would want people to hinder you at a time of need would be your GP surgery!
    Last edited by moonface; 01-01-2019 at 11:59 PM.

  6. #6
    Quote Originally Posted by Priffy View Post
    I think when most people think of tampering
    What about someone who really struggles to go public places, manages to muster the strength to go to his GP which he hasn't been to for years and years,goes in and attempts to get some help and states his deep personal issues and some unfit receptionist send a report to a tribunal stating he 'goes out once or twice a week' leaving out 'with support'!

    Lying about it and then having the nerve to state it's what she thought was 'doctors opinion' you couldn't make it up! I think this is wicked especially when someone is suffering as a result of all this messing about.

  7. #7
    I appreciate what you're saying which is why I said " you live and learn ".
    I was just pointing out that unless you'd come across that situation, then people ( I ) wouldn't have thought of that scenario and indeed it's associated consequences and I agree, lying is entirely wrong especially when it could lose someone some much needed help.

    It's an awkward situation when you have a complaint regarding your Dr's surgery because there is always the fear they could take you off their books,
    however, it doesn't seem right that a receptionist can withhold information at their own discretion.

  8. #8
    Quote Originally Posted by Priffy View Post
    fear they could take you off their books,
    however, it doesn't seem right that a receptionist can withhold information at their own discretion.
    Oh no worry of that Priffy, i'm going to be changing my surgery anyway,your right i did not even know they could edit a patient record to begin with,i thought they were sort of locked by security into a computer and they just click print.

    This is a tricky one as apparently the only thing i can do is send in a complaint to the head of the surgery who i suspect would not end up doing anything,have my tribunal effected by a falsified report and nothing will be done about it,the Judge isn't going to personally call or inquire into my doctors surgery and it all gets forgotten about.

    All i feel i have the power to do at the moment is name and shame but i'll leave that for a later time if necessary ,hopefully my next Judge does the right thing and has some due diligence about him/her!

  9. #9
    Although this link is from April 2013 I am wondering if this may be the cause of the problem.

    PIP factual report form revealed
    Category: Latest news
    Created: 23 April 2013
    GPs are being paid £33 a time to complete factual report forms in relation to personal independence payment, it has been disclosed.
    Details of the payment and a copy of the new GP factual report form have been published on the Pulse website for GPs.
    The form instructs GPs to:
    Please write down facts rather than opinion. We require an objective report - please only include information about symptoms that are recorded in the patient’s records and information about disabling effects that you or another healthcare professional have directly observed.
    Please complete all sections as fully as possible but write “not known” if appropriate. “Not known” can be helpful.

    There are then the following sections for GPs to complete:
    1. Disabling conditions.
    Please list conditions or impairments which affect the patient’s functional ability.
    2. History of condition(s).
    Include details of any relevant special investigations.
    3. Symptoms and variability.
    This is especially helpful in conditions that fluctuate. It should be based on information in the clinical record. Include both day-to-day and longer-term fluctuations. Include the frequency and duration of exacerbations. Please also specify if the condition is well controlled.
    4. Relevant clinical findings.
    Entitlement is based on the impact of the individual’s impairment or health condition(s) on their everyday life. Please provide details of examination findings related to the severity or impact of any health conditions or impairments.
    5. Treatment – Current, planned, response and prognosis
    Please provide details of drug and non drug treatment and aids and appliances used (prescribed or, if known, non-prescribed). Please specify frequency of treatment and, for medication, dose as relevant.
    6. Effects of the disabling condition(s) on day to day life.
    If known, it would be helpful to have information on the patient’s ability to:
    Manage their health conditions and treatment
    Walk or move around
    Get somewhere on their own
    Make simple decisions
    Prepare, cook and eat food
    Wash, bathe and use the toilet/ manage incontinence
    Dress and undress
    Only include information that has been confirmed by a health professional. Please state if this is not known.
    7. Does the patient have a history of threatening or violent behaviour?
    8. Could your patient travel to an assessment centre by public transport or taxi?
    9. Additional information
    Use this section if there was insufficient space in one of the previous boxes OR to add important relevant factual information that has not been written in the body of the report. Do not use the section to provide an opinion.
    Unfortunately, if past experience is any guide, many of these forms will be filled in by non-medical staff using patient notes and may then simply signed off by the GP who may or may not have good knowledge of the patient and may or may not have read the completed form in detail.
    I try my best

  10. #10
    I see your point
    'going out twice a week' and 'with support'
    neither of those are opinion
    - 'they could do with some support' would be opinion

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