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Case ref:201804064
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Date:October 2020
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Body:A Medical Practice in the Tayside NHS Board area
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Sector:Health
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Outcome:Not upheld, no recommendations
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Subject:record keeping
Summary
Mrs C complained that the practice had failed to properly investigate a series of complaints she had made about entries in her and her children's medical records. Mrs C believed the practice's conclusions were unreasonable given the available evidence. Mrs C also complained that the practice failed to communicate appropriately with her.
We took independent advice from an adviser on general practice medicine. We found that the practice had reasonably and appropriately investigated the complaints brought to it by Mrs C and had communicated reasonably with her. Some of the medical record entries that Mrs C objected to were the opinions of the GP following their encounter with her. We considered that it was reasonable for medical records to contain subjective opinion and it was not possible to amend or delete the entries Mrs C was concerned about. In addition, the practice had offered Mrs C the opportunity to place notes in her medical records, indicating that she disagreed with the content or tone of the entries. Mrs C had not responded to these offers. We did not uphold any of Mrs C's complaints.