Test Results
- Why may a result say it is abnormal but no action required?
The clinician may have already treated the condition, or it might be that a result is outside the normal range but there is no specific action needed at this time.
- Why might a test result say you need to contact me, but I haven’t heard from you?
Please allow up to 5 working days for us to contact you.
Diagnosis
- I do not agree with a diagnosis on my medical records?
If you are unsure about a particular diagnosis, you should arrange to discuss it with the clinician who originally added it. If the issue is not urgent, you may wish to wait until you next see the GP.
- There’s a diagnosis on my notes that was later found to be inaccurate. Why is it still there?
If a patient is diagnosed by a clinician as suffering from a particular illness or condition, but it is later proved that this is not the case, it is likely that their medical records should record both the initial diagnosis (even though it was later proved to be incorrect) and the final findings. Whilst the medical record shows a misdiagnosis, it is an accurate record of the patient’s medical treatment. As long as the medical record contains the up-to-date findings, and this is made clear in the record, it would be difficult to argue that the record is inaccurate and should be rectified.
Missing entries
- Why can I not see a consultation or letter I had?
You may sometimes expect to see an entry such as a consultation or letter. Where entries contain personal information of other people, we are required to keep these private to protect the individual.
Sensitive entries such as safeguarding matters may not be visible to protect the individuals concerned.
Access to my Medical Records
- I do not have automatic online access to my medical records, why is this and can I get access?
There will be some patient records that will not have automatic access from 1st November 2023, due to patient safety. If you wish to have online access please make a request to the practice, in which the GP will then review your access request and medical notes and either access will be granted, or a reason will be provided as to why access cannot be provided. The timeframe will be 6-8 weeks, however if access is granted you will be able to see your records back to the 1st November 2023.
Information you think is wrong?
- I don’t agree with something in my notes, what can I do?
The Practice staff always try to add their medical notes during or shortly after a consultation to make sure they provide the most accurate record they can of what happened during the consultation. There will often be differences in exact recollections between two people but hopefully the important facts can generally be agreed upon. Where there are factual inaccuracies there is a right to rectification, and amendments can be added to notes highlighting where you contest the stated facts. You can find more information about this on the ico.org.uk website by searching under “Right to Rectification’.
If you think, there’s something in your medical record which isn’t from your GP / Practice please contact that service not the practice i.e. If it’s a letter from someone, a hospital department for example, please contact them directly or tell the service’s Customer Service team.
Abbreviations on my Medical Records
- There are abbreviations use in Medical Record, what do they mean?
Please see information from NHS England on abbreviations you may find in your health record – Abbreviations you may find in your health records – NHS App help and support – NHS (www.nhs.uk)
