[lettie]

I'm afraid that medical records are as prone to PC as anything else. We have to be extremely careful what we write down (even when it's true), as the patient may see the records and complain.

This causes problems sometimes in that........ if a doctor or nurse suspected that a child was being abused, repeated visits to A&E, the history of an injury which doesn't fit to the actual injury etc. they cannot write down their suspicions until they can prove it. If their suspicions are wrong then the child's mother complains, demands public apologies, compensation etc. If they are right then you end up with a Victoria Climbe situation where everybody knew but nobody acted or wrote owt down.

Some of the funniest things I have come across in old medical records still make me laugh to this day for example.....

It was 1989 and I was a student nurse on a medical ward. We had a middle aged man who was brought in as an emergency with chest pain 6 times in 8 weeks. He was a regular and had a massive tome of medical records due to his excessive admissions and general timewasting. One of our consultants had written in his notes (in big red letters).....

'This man is a cardiac neurotic who is more likely to die from being hit by a bus than a heart attack.'

Several months later I was working on A&E and sure enough........ the same fella was brought in after a road traffic accident, sadly he died..