– Important information can be lost if it is not recorded in the journal. Then it is the patient who ultimately becomes the loser, says Jannicke Bruvik. She is the national patient and user representative. Bruvik believes that it is particularly important to have supplementary medical records when the patient has to change doctors or be referred to a specialist. – That is why it is important for all patients that relevant and important information must be recorded in the medical record, she says. Bruvik speaks on a general basis. news has recently written several cases about Nav’s inspections of doctors and access to patient records. Doctor Svein Gisle Apeland is one of ten doctors who have today temporarily lost the right to write sick notes. Since 2018, 57 doctors have lost this right. Although there is a GP crisis in Norway. After Apeland came forward, he has also received support from several GPs. The case has also been up for debate in Dagsnytt 18. Apeland was blacklisted by Nav due to a lack of record keeping. He has lost the right to call his patients sick for nine months. Focuses on the patient – not the medical record GP Apeland believes that the most important thing is the patient. – What we are here to do is take care of patients. We will help them in an unclear system. We don’t always have time to write long journals, says GP Svein Gisle Apeland. – What happens when a patient changes doctors? Svein Gisle Apeland is one of 57 doctors who in the last four years have lost the right to report their patients sick. Photo: Rosa Irén Villalobos / news – When I get new patients, I always do a primary interview with them. You never take over a patient record slavishly, says Apeland. He points out that serious matters, such as hospital admissions, medication use and allergies, are always recorded in the records. When Apeland lost the right to report sick to its patients, Nav reacted to the lack of follow-up records. 15 out of 1,500 patient records were checked. – But it’s only around 9 percent of all the medical records I have in that period, says the GP. The medical association believes that the medical record is important. Primarily as a tool in the treatment and follow-up of the patient. But also as documentation for Helfo and Nav. – Inadequate record keeping can also be a danger to patient safety, says the head of the Association of General Practitioners, Nils Kristian Klev, to news. He still has the impression that the vast majority of doctors have good quality records and use them as an important work tool. – But there will necessarily be some different views on what is the appropriate scope of documentation, says Klev. Nav carries out between 80 and 90 inspections each year. Then they check, among other things, the doctors’ record keeping. Photo: Alf-Jørgen Tyssing / news Time pressure for doctors The lack of GPs means that 235,000 patients are without a GP in Norway. The GPs have for a long time pointed out that they do not get enough time per patient. – We are constantly assigned new tasks, even though we have said it will go beyond the quality. And then they come afterwards and criticize us for not accounting for absolutely everything. It shouldn’t be like this, says Apeland. Writing a journal is required by law. The medical association also believes it is necessary. – But there has been a discussion about how extensive the documentation should be, for example linked to Nav’s requirement for sick leave, says Klev. Head of the Association of General Practitioners, Nils Kristian Klev. Photo: Arne Sørenes / news He adds that the medical association is working together with Nav to see how the exchange of information between Nav and the doctors can be streamlined and simplified. – It is both about better digital solutions, but also about not asking for more information than is necessary and that previously provided information is to a greater extent re-used, says Klev. Patient center Jannicke Bruvik understands that GPs have a lot to do. At the same time, she believes that the job must be done properly. – You can’t say that you have such a bad time that you can’t keep a journal. Then you don’t do your job, says Bruvik. Every year, the Patient Ombud receives inquiries from patients about something missing from the medical records. – But it does not only apply to fixed laws. This also applies to psychologists, physiotherapists and hospital therapists, she says. GP Svein Gisle Apeland has now complained about the decision from Nav.
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The patient ombudsman believes that the lack of record-keeping affects the patients – news Rogaland – Local news, TV and radio
