Data Protection Act - Medical Records

[heisenberg]

Hi all,

I recently went to see a psychotherapist via the NHS with a view to receiving treatment.

I very briefly discussed legal proceedings that had been dismissed and essentially said no more.

However, this retched fellow has happily written to my GP and therein made up a load of nonsense.

I have contacted my GP Practice Manager and asked the letter be deleted from my notes as it is factually inaccurate. He essentially replied in writing suggesting the burden of proof if is on me to prove they are inaccurate.

Is this correct? How on earth do I prove such a conversation never happened? Is the burden of proof definitely on me or is the onus on the practice to keep the notes factually correct?

Any suggestions/guidance would be seriously appreciated.

[wales01man]

Re: Data Protection Act - Medical Records

Why would the therapist lie?

[Johnboy007]

Re: Data Protection Act - Medical Records

You have the right to get a copy of the information that is held about you. This is known as a subject access request.
This right of subject access means that you can make a request under the Data Protection Act to any organisation processing your personal data. The Act calls these organisations ‘data controllers’.
You can ask the organisation you think is holding, using or sharing the personal information you want, to supply you with copies of both paper and computer records and related information.
Organisations may charge a fee of up to £10 (£2 if it is a request to a credit reference agency for information about your financial standing only).
There are special rules that apply to fees for paper based health records (the maximum fee is currently £50) and education records (a sliding scale from £1 to £50 depending on the number of pages provided).
However, it is important to remember that not all personal information is covered and there are ‘exemptions’ within the Act which may allow an organisation to refuse to comply with your subject access request in certain circumstances.
As wales stated, 'Why would the therapist lie?

[wales01man]

Re: Data Protection Act - Medical Records

When either of us visits a clinic away from the surgery we get unless we decline it a copy of the letter sent to the GP.
Can the OP ask the therapist for this?

[heisenberg]

Re: Data Protection Act - Medical Records

Why would the therapist lie?

I have raised a formal NHS complaint about this and his other conduct. I suspect it all relates to his discriminatory and judgemental behaviour. This is just the tip of the proverbial iceberg.

I have already seen the letter in question. In fact, I had sight of it before the practice did.

[wales01man]

Re: Data Protection Act - Medical Records

Difficult to prove those accusations?

[bluebottle]

Re: Data Protection Act - Medical Records

Absolutely, JB. There are special rules that apply to disclosures from medical records. When you say "psychotherapist", do you mean Clinical Psychologist? Also, is this "psychotherapist" registered with the Healthcare Professionals Council (HCPC)? Any person working in medical, nursing, midwifery or paramedical professions has to be registered with one of the following -

General Medical Council (GMC) - Medical Practitioners;
Nursing & Midwifery Council (NMC) - Nursing and Midwifery;
Healthcare Professionals Council (HCPC) - Any medical or paramedical profession not being medical, nursing or midwifery, e.g. physiotherapists, paramedics, occupational therapists, radiologists;
NHS Register of Alternative Therapists - Includes acupuncturists, nutritional therapists and disciplines that do not qualify for registration with the GMC, NMC or HCPC.

[enquirer]

Re: Data Protection Act - Medical Records

I recently went to see a psychotherapist via the NHS with a view to receiving treatment.

NHS liable.

I very briefly discussed legal proceedings that had been dismissed and essentially said no more. However, this wretched fellow has happily written to my GP and therein made up a load of nonsense.

A similar thing happened to me many years ago. Some twerp created a false record featuring a conversation with me that never happened. I resolved the problem by gaining access to the file and removing the document concerned. That was back in the days of paper, of course.

Unfortunately, the NHS is crawling with wannabee doctors, all of whom are consumed with a sense of their own importance. The less substance there is to their occupation, the worse they are.

I have contacted my GP Practice Manager and asked the letter be deleted from my notes as it is factually inaccurate. He essentially replied in writing suggesting the burden of proof if is on me to prove they are inaccurate. Is this correct?

No.

They may enter a medical opinion in your records which may, or may not be, accurate. That's because at the end of the day, an opinion is little more than an educated guess. The only exception is when the opinion is so off the wall, that it must either be a lie or the result of gross incompetence.

What they may not do is enter a statement of fact, when that fact is wrong. This is what has happened here - the psychotherapist has created a completely false record.

How on earth do I prove such a conversation never happened? Is the burden of proof definitely on me or is the onus on the practice to keep the notes factually correct

If they state that it is a fact, the onus is on them to prove that it is so. They created the record, not you, so it is up to them to justify it.

Any suggestions/guidance would be seriously appreciated.

Initiate the NHS complaints procedure.

Do not be bamboozled into dealing with this at local level (they often tell people that you 'have' to deal with the practice. You don't - this is a lie that they use in order to fiddle their complaint figures). Go straight to the top - write directly to the CEO, heading the letter 'Formal Complaint'.

I would be inclined to complain about the practice to the Clinical Commissioning Group on two grounds - factual inaccuracy of the records, and that practice staff sought to mislead you. If the therapist was directly employed by the practice, mention serious misconduct as well. If you saw the therapist at a hospital, also complain to the Hospital Trust.

Put in a request for a printout of your medical records. Get this as soon as possible, lest they be filleted.

[heisenberg]

Re: Data Protection Act - Medical Records

Absolutely, JB. There are special rules that apply to disclosures from medical records. When you say "psychotherapist", do you mean Clinical Psychologist? Also, is this "psychotherapist" registered with the Healthcare Professionals Council (HCPC)? Any person working in medical, nursing, midwifery or paramedical professions has to be registered with one of the following -

General Medical Council (GMC) - Medical Practitioners;
Nursing & Midwifery Council (NMC) - Nursing and Midwifery;
Healthcare Professionals Council (HCPC) - Any medical or paramedical profession not being medical, nursing or midwifery, e.g. physiotherapists, paramedics, occupational therapists, radiologists;
NHS Register of Alternative Therapists - Includes acupuncturists, nutritional therapists and disciplines that do not qualify for registration with the GMC, NMC or HCPC.

This character refers to himself as Counsellor, Psychoanalytic Psychotherapist, Psychotherapist though I would consider him nothing more than a clown.

[wales01man]

Re: Data Protection Act - Medical Records

Why are we now expected this is turning into a Conspiracy and cover up?
Easy to revisit the therapist and ask what is going on before starting complaints that in all probability will side with therapist.

[Johnboy007]

Re: Data Protection Act - Medical Records

This character refers to himself as Counsellor, Psychoanalytic Psychotherapist, Psychotherapist though I would consider him nothing more than a clown.

I agree with Wales..

[heisenberg]

Re: Data Protection Act - Medical Records

NHS liable.


A similar thing happened to me many years ago. Some twerp created a false record featuring a conversation with me that never happened. I resolved the problem by gaining access to the file and removing the document concerned. That was back in the days of paper, of course.

Unfortunately, the NHS is crawling with wannabee doctors, all of whom are consumed with a sense of their own importance. The less substance there is to their occupation, the worse they are.


No.

They may enter a medical opinion in your records which may, or may not be, accurate. That's because at the end of the day, an opinion is little more than an educated guess. The only exception is when the opinion is so off the wall, that it must either be a lie or the result of gross incompetence.

What they may not do is enter a statement of fact, when that fact is wrong. This is what has happened here - the psychotherapist has created a completely false record.


If they state that it is a fact, the onus is on them to prove that it is so. They created the record, not you, so it is up to them to justify it.


Initiate the NHS complaints procedure.

Do not be bamboozled into dealing with this at local level (they often tell people that you 'have' to deal with the practice. You don't - this is a lie that they use in order to fiddle their complaint figures). Go straight to the top - write directly to the CEO, heading the letter 'Formal Complaint'.

I would be inclined to complain about the practice to the Clinical Commissioning Group on two grounds - factual inaccuracy of the records, and that practice staff sought to mislead you. If the therapist was directly employed by the practice, mention serious misconduct as well. If you saw the therapist at a hospital, also complain to the Hospital Trust.

Put in a request for a printout of your medical records. Get this as soon as possible, lest they be filleted.

Thanks enquirer. I have already had my complaint referred to the local Medical Director. I have asked her to rectify this but will hit the Practice Manager with a letter I'm about to print and send too.

[heisenberg]

Re: Data Protection Act - Medical Records

Why are we now expected this is turning into a Conspiracy and cover up?
Easy to revisit the therapist and ask what is going on before starting complaints that in all probability will side with therapist.

The 'therapist' essentially discharged me and ceased any further communication, Went to see my GP the following day who rang the respective department and asked him to call me. Do you think he did?

I should add that when I asked why I was not being afforded therapy this man just got up and showed me the door. All detailed in my complaint...

[heisenberg]

Re: Data Protection Act - Medical Records

I agree with Wales..

Explain?

[wales01man]

Re: Data Protection Act - Medical Records

Make the complaint by all means that's your right but lets move away from wild theories he may just have been an ahole who took a dislike to the OP or thought they were a waste of time.
Getting to the truth from the Therapist is probably not going to happen.