I have never claimed to hold perfect records.
My own contain working diagnoses that evolve into correct ones over time. The mobility of GP patients means ‘working diagnosis’ may become coded as ‘fact’.
The ‘penicillin allergy’ codes are a case in point. When reviewed, patients with penicillin allergy often give a history of rash after penicillin for symptoms I would call a viral URTI. The rash was probably viral but I have to take it as allergy.
Let us remember the record was developed for one purpose and is now being put to another. It’s a bit like asking a military tank to swim. It can be made to do so, but you would not regard it as effective.
The data in GP notes may be sincerely held to be correct. Just because a GP holds a set of records does not mean they made any error within them.
No notes in any format can substitute for a contemporaneous history of the presenting complaint, antecedents to the current issue and a diligent personal assessment of the patient.
From Dr Andrew Mimnagh