Understanding Your Medical Record
It is now more common for patients to view their medical records through online portals or apps. We understand that sometimes the information recorded may appear confusing, or you may feel it does not fully reflect your medical history.
There are several technical and clinical reasons why your record might appear this way:
1. The Limitations of “Clinical Coding”
To allow different parts of the Health and Social Care (HSC) system to communicate, we use a standardised electronic coding language.
- System Approximations: While there are thousands of codes, they cannot cover every unique or rare condition. In some cases, we must use the “closest match” available within the system.
- Clinical Terminology: Medical terms often have a very specific clinical meaning that differs from everyday conversation. These are used to ensure hospital specialists and other clinicians can interpret your history accurately and quickly.
2. Discrepancies or Dating Errors
We strive for 100% accuracy, but errors can occasionally occur—particularly when older paper records were originally digitised.
- How to notify us: If you spot a factual error (such as an incorrect date or a clearly wrong diagnosis), please let us know.
- Contact Method: Please submit your query in writing (via email or letter) rather than by telephone. This allows our administration team to investigate the audit trail thoroughly and ensures we have a clear record of the request.
- Appointments: Please do not book a GP appointment solely to discuss a clerical or administrative error in your record. Written requests are processed more efficiently and keep clinical appointments available for those with urgent medical needs.
3. Historical Data and Summaries
Your medical record is a lifelong document. You may find that older entries are brief or lack the detail of modern electronic notes. This is often a result of how information was “summarised” when the practice transitioned from paper records to digital systems. We must accept and work with these historical summaries as they form the foundation of your digital file.