Access to medical documentation / FOI application

mstq

Hi there

So I had a visit today in a HSE clinic with a consultant. After trying to get a diagnosis for 2 months I've been refused to be provided with one. I asked for patient report [as one was made] and I was refused an access to that as well. I was also refused access to patient file.

1. My first question would be if they have a right to do that? My belief was that patient records are somewhat of a "property" and I have unrestricted right to access those at any time (as long as it's reasonable, eg. during consultation)
I also believed that I have an irrevocable right to receive a diagnosis, whether it outlines any conditions or it states that I'm healthy as a horse.


2. I looked up the application for release under the freedom of information act which is here - http://foi.gov.ie/faqs/how-do-i-make-an-foi-request/

The application says that I have to return the application form to the body which holds the record - does this mean I have to return it to HSE Headquaters or to the HSE clinic?

Please advise

davo10

mstq wrote: »

Hi there

So I had a visit today in a HSE clinic with a consultant. After trying to get a diagnosis for 2 months I've been refused to be provided with one. I asked for patient report [as one was made] and I was refused an access to that as well. I was also refused access to patient file.

1. My first question would be if they have a right to do that? My belief was that patient records are somewhat of a "property" and I have unrestricted right to access those at any time (as long as it's reasonable, eg. during consultation)
I also believed that I have an irrevocable right to receive a diagnosis, whether it outlines any conditions or it states that I'm healthy as a horse.


2. I looked up the application for release under the freedom of information act which is here - http://foi.gov.ie/faqs/how-do-i-make-an-foi-request/

The application says that I have to return the application form to the body which holds the record - does this mean I have to return it to HSE Headquaters or to the HSE clinic?

Please advise

As someone who works in the health profession, I have never heard of a medical professional "refusing" to give a diagnosis. Sometimes diagnosis are reserved pending further investigations or opinions so as not to offer an incorrect diagnosis. Was your visit today requested by a third party like an employer or insurance company?

Corruptedmorals

Normally consultants are amenable to copying in patients/parents of patients on the medical report. At my (paediatric) clinic us secretaries will send out copies of letters to parents once details are verified.

More extensive requests come under the FOI act and usually require a formal request of records- detailing what specifically is needed although they do do entire hospital charts- and payment of I think 6 or 8 euro. This would be sent c/o medical records to the hospital. If the clinic is entirely separate to the hospital, ring reception and ask how to go about it. Have you contacted the secretary to see if they will send you your letter?

As a short-term measure you could ask your GP's clinic staff if they will send you your letters written by the consultant, you could say the secretary is on holidays or something.

Pat Mustard

mstq wrote: »

The application says that I have to return the application form to the body which holds the record - does this mean I have to return it to HSE Headquaters or to the HSE clinic?

I would send an FOI application for a record to the place that holds the record.

Victor

mstq wrote: »

FOI application

You need to look at the Data Protection Acts (information about people), not the Freedom of Information Acts (information about public organisations).

mstq wrote: »

After trying to get a diagnosis for 2 months I've been refused to be provided with one.

Do they have one? Not every situation is readily diagnosable.

In certain cases, medical staff can decline to give a diagnosis, if they believe it isn't in the best interests of the patient.

mstq wrote: »

1. My first question would be if they have a right to do that? My belief was that patient records are somewhat of a "property" and I have unrestricted right to access those at any time (as long as it's reasonable, eg. during consultation)

That isn't my understanding. The record is the property of the clinic. You have a limited right of access. If you had an unrestricted right of access, it would be difficult for the doctors to be candid in their notes. It might also contain misfiled documents, relating to other parties.

The application says that I have to return the application form to the body which holds the record - does this mean I have to return it to HSE Headquaters or to the HSE clinic?

It would be the clinic. However, ask the clinic who their Data Protection officer is.

Batzoo

Victor wrote: »

That isn't my understanding. The record is the property of the clinic. You have a limited right of access. If you had an unrestricted right of access, it would be difficult for the doctors to be candid in their notes. It might also contain misfiled documents, relating to other parties.

This is only partially correct. The clinic can claim the rights to the documentation. But the patient has full and unrestricted rights to all the information contained in this documentation as long as it pertains to them regardless of the candor.

If its a public clinic the Freedom Of Information act should cover it. If its a private clinic the Data protection act will do.

If you believe they are holding something back, seek legal advice.

But as advised above, It may be because they have not reached a consensus on a diagnosis. Normal procedure is see your GP, GP refers to consultant. Consultant writes a letter and sends letter back to GP. GP will then discuss prognosis and options/ further investigations. Two months is not long on the HSE merry-go-round. Were you refered to the consultant by your GP, if so, go back to your GP.

Pat Mustard

Victor wrote: »

You need to look at the Data Protection Acts (information about people), not the Freedom of Information Acts (information about public organisations).

That makes sense Victor but the HSE will release medical records to people who make their requests under the FOI Act.

Carawaystick

Victor wrote: »

You need to look at the Data Protection Acts (information about people), not the Freedom of Information Acts (information about public organisations).

FOI is for info *held* by public bodies

Such as personal medical information held by the hse

etymon

Don't forget a lot of the notes will be in medical shorthand and all doctors write their notes conscious anyone could get a FOI anytime so you may not find out much. You will need a doctor to translate in all likelihood. I would also be of the view that nobody is refused a diagnosis, it is more likely that your symptoms do not in fact fit any diagnostic criteria. In my line of work plenty of people demand a diagnosis and there isn't one, which I do explain, but of course some patients will not be satisfied with this. My notes would clearly reflect what has been ruled out.

Batzoo

etymon wrote: »

Don't forget a lot of the notes will be in medical shorthand and all doctors write their notes conscious anyone could get a FOI anytime so you may not find out much. You will need a doctor to translate in all likelihood.

Its not a big secret. Medical shorthand would have to have some general publication that explains the meaning. Google is your friend. Doctors cant write cryptic information on a patients notes that only they understand. What if your doctor passed and you had to take your notes to another doctor. Better call in Robert Langdon to decipher this.If they did write cryptic information that only they understand they could potentially leave themselves open to a lawsuit.

I know some doctors have a high opinion of their expertise, but ultimatly they are payed by a patient and subsidised by taxes to provide a service. They are working for the patients like any other contractor, plumber, electrician...

etymon

Batzoo wrote: »

Its not a big secret. Medical shorthand would have to have some general publication that explains the meaning. Google is your friend. Doctors cant write cryptic information on a patients notes that only they understand. What if your doctor passed and you had to take your notes to another doctor. Better call in Robert Langdon to decipher this.If they did write cryptic information that only they understand they could potentially leave themselves open to a lawsuit.

I know some doctors have a high opinion of their expertise, but ultimatly they are payed by a patient and subsidised by taxes to provide a service. They are working for the patients like any other contractor, plumber, electrician...

Ha. I'm not saying we have any secret codes or special superiority here and I have no issue with patients having information to their notes. In fact in a lot of cases it would make the issue of 'non diagnosis' easier as it would explain stuff. All I meant was the OP would probably need the assistance of another doctor or maybe a nurse who works in the field in question to go through the notes with them. There probably is stuff online but for example TSH means 'thyroid stimulating hormone' to some doctors, 'thoughts of self harm' to me...

Batzoo

etymon wrote: »

There probably is stuff online but for example TSH means 'thyroid stimulating hormone' to some doctors, 'thoughts of self harm' to me...

I was not having a go at you or at doctors in general. I have seen doctors through the years that seemed to go above and beyond the norm, real life Doc Martins. Just from experience a proportion of doctors feel that their time is more important than the patients and cant take the extra few seconds to clearly write on documents or explain coherently to patients. This shorthand information is not exclusive to the doctor that wrote it and may need to be seen by other medical professionals so should be clearly written and unambiguous. To have one acronym that could mean several different symptoms, could lead to a whole lot of hurt for a patient if misread and treated wrongly. This will only get worse now, when a large proportion of doctors in the HSE are now speaking English as a second language. Unfortunately, the potential for lawsuits is only going to increase.

Luckily enough I have never had to see a doctor in my life but have assisted several older people through the system at all levels. I have received prescriptions on their behalf from doctors and taking them to the pharmacist only to be told that they cant read the writing (chicken scrawl) and they (the pharmacist) need to contact the original doctor to find out what is written. When the hospital/doctor is contacted, inevitably they are unavailable and messages have to be left. This can delay the prescription by a day or two in some cases all because the doctor was in too much of a rush to write legibly. Again, I have contacted doctors (GP) offices on behalf of said people to arrange a reoccurring prescription only to be told that three days notice are required for this to be written. I understand doctors are busy, but sometimes from the outside it just looks like an artificial type of busy.

Pat Mustard

A lot of PI lawyers have a degree of familiarity with 'medical shorthand' (if it is called that? ), as it pertains to PI actions.

gctest50

Batzoo wrote: »

............ I have received prescriptions on their behalf from doctors and taking them to the pharmacist only to be told that they cant read the writing (chicken scrawl) and...............

why did you not request a more clearly written replacement presciption there and then ?

Batzoo

gctest50 wrote: »

why did you not request a more clearly written replacement prescription there and then ?

The prescription was not for me. I collected it from the doctors office in an envelope with the patients name on it. I never saw the actual doctor and had no reason to. I returned the unopened envelope to the intended person who asked me to collect it for them. I brought it to the pharmacist and a few minutes later the pharmacist took me aside and asked if I knew what was written on the prescription. I could make out an M, N and Z and a lot of squiggles. Even if it was spelled in block capitals, I still would not have known as I am not overly familiar with medication. I have taken about 8 panadol in my entire life.

I will admit that over the last few years, prescriptions from the GP's do appear to be printed and leads to less chance of error, although I have seen a few with the chicken scrawl meds added to the bottom of the printed prescription by the GP.

On a side note, I do wish a lot more people would go to their local pharmacist with minor sniffles and aches rather than A&E. I have seen pharmacists take patients/customers aside, often a private room and sit down and go through each medication and explain what it's for and how to take it. Only takes five minutes but is an invaluable service especially for the elderly.

mstq

Viktor wrote:

Do they have one? Not every situation is readily diagnosable.

Yes, I've been provided with diagnosis on few occasions before - 5 times orally and once in writing as I needed it in writing. This time around, when I've been getting really pissed with the quality of treatment I've been receiving (eg. different diagnosis each time) I've requested diagnosis from both of my consultants in writing, outlining all of their findings, etc.

Viktor wrote:

In certain cases, medical staff can decline to give a diagnosis, if they believe it isn't in the best interests of the patient.

Not a case in this situation.

Viktor wrote:

it would be difficult for the doctors to be candid in their notes

Putting ones interest ahead of the patients is called malpractice.

etymon wrote:

You will need a doctor to translate in all likelihood

Checked the relevant statue, the information must be legible to the person receiving the information.


I've made an application under S.4 of the Data Protection Act, so we will see how that goes. Since the consultants involved know they have been negligent (their own admission), they realize that any diagnosis they would give (whether correct or nor) would be a material evidence in my case.