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Letter: Getting it right when it comes to patient notes

When it comes to sharing information we seem to have forgotton 'Nothing about me without me' says Dame June Clark
patient info

When it comes to sharing information we seem to have forgotton 'Nothing about me without me' says Dame June Clark

I was disturbed to read Marc Cornocks reply to your reader who asked Can I read my own hospital notes? (Nursing Standard October 12).

His reply may be correct if it relates to medical notes (I am not an expert) but it is certainly wrong if it applies to nursing notes.

Sharing nursing notes with a patient is an essential part of care planning and involving the patient in his/her care, which nowadays we are strongly encouraged to do.

Community nurses have for many years routinely left the nursing notes in the patients own home, partly to maintain continuity of care when care is

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When it comes to sharing information we seem to have forgotton 'Nothing about me without me' says Dame June Clark

I was disturbed to read Marc Cornock’s reply to your reader who asked ‘Can I read my own hospital notes?’ (Nursing Standard October 12).

His reply may be correct if it relates to medical notes (I am not an expert) but it is certainly wrong if it applies to nursing notes.

Sharing nursing notes with a patient is an essential part of care planning and involving the patient in his/her care, which nowadays we are strongly encouraged to do.

Community nurses have for many years routinely left the nursing notes in the patient’s own home, partly to maintain continuity of care when care is provided by several visiting nurses, but also, importantly, to support and involve  relatives and other informal carers.

Pregnant women receiving care from midwives have for years carried their own notes. In hospitals the nursing notes should be kept at the bottom of the bed, accessible to the patient and, subject to the patient’s consent, for discussion with relatives.

Even in respect of medical records I do find Mr Cornock’s attitude to somewhat patronising and contrary to modern approaches to patient care patients (for example: ‘A health record could be written in a language the patient is unfamiliar with and may need translating’). 

Have we forgotten the mantra ‘Nothing about me without me’ and the furore that followed the Liverpool end of life care pathway?

Explaining things such as technical terms or diagnostic procedures is an essential part of the nurse’s role in the nurse-patient partnership – you may find that the patient knows far more about his/her condition than you do!

June Clark DBE, RN

Marc Cornock responds

I agree with Dame June’s assertion that nurses should be involving patients in their care and writing in patient notes in such a way that patients can understand them.

However the examples she gives of patients having access to their notes is not a universal feature for all patients. Indeed many wards and units do not place patient notes at the end of a bed but hold them in a collective area.

Unfortunately, in the notes I have seen, nurses are as guilty as others of writing in a way that the patient would not understand, for example the use of abbreviations and shorthand language.  There can be a difference between what a nurse may say to a patient to explain a procedure to them and the way it is recorded in the notes.

The central tent of my response, that a patient does not have an automatic right to their notes, is legally correct. The fact that nurses are willing to share their notes means they are working to a higher standard and that's to be welcomed, but it is not the current universal standard. 

Marc Cornock

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