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Obtaining your medical records
Medicine involves numerous professionals working together, some medically qualified and others not.
Below is a list of the various personnel that you will come across when reviewing medical records.
Doctors are medically qualified and must complete a medical degree, foundation training and speciality training.There are various grades of doctors:
Foundation Year 1: In the medical records this will be abbreviated as FY1. You may also see the old abbreviation, PRHO. These doctors are in their first year of the Foundation Program and are therefore in their first year out of their medical degree. They will be very inexperienced and will be heavily supervised.
Foundation Year 2: Will be abbreviated as FY2 or SHO. These doctors are in their second year of the Foundation Program.
Speciality Registrar: Abbreviated as SpR [name of speciality]. For example, you may see in the records SpR Neurology. These doctors are in their speciality training and have therefore completed the Foundation Program.
GP Registrar: These doctors have commenced the GP training route rather than the hospital route. They are effectively Specialist Registrars but have chosen to practice general medicine.
General Practitioner: An autonomous doctor specialising in general practice. They will have completed the necessary training. They are the equivalent of a hospital Consultant.
Consultant: Consultants are autonomous specialists in their chosen field. They will have completed their required training.
Nurses are at the forefront of patient care. Nursing has become much more specialised over the years and there are now a number of different types of Nurses:
Practice Nurses: Practice Nurses specialise in general practice and are therefore based within a GP practice. Often, Practice Nurses will specialise in a specific area of general practice, for example Diabetes, Coronary care and asthma. These Nurses will be responsible for all patients within the practice suffering from, for example, diabetes. They will be responsible for the monitoring and treatment of the conditions.
Nurse Practitioners: Nurse Practitioners are Nurses who have undergone the practitioner training (post graduate level training) enabling them to be more involved in a patient’s care. They will be involved in the diagnosis and treatment of certain conditions. A patient would usually be assessed by a Nurse Practitioner on initial attendance at Accident and Emergency.
Nurse Consultants: Nurse Consultants are very experienced Nurses who specialise in a particular area of medicine within a hospital.
Specialist Nurses: Because nursing (and medicine in general) has become more specialised over the years there are now Nurses that include: SCBU Nurses, Psychiatric Nurses, and Nurses specialising in Urological medicine. They are nurses that have built up many years of experience within the field and are often Nurse Practitioners, but not necessarily so.
Physiotherapists work either within a hospital setting or within the community usually based at a GP practice or in private consulting rooms. Their aim is to develop, maintain and restore maximum movement and functional ability, often following an accident.
Physiotherapists will be heavily involved in the rehabilitation of patients with brain, spinal and severe orthopaedic injuries.
Psychologists are trained in the recognition of psychological symptoms, in quantifying these symptoms and in attempting to treat them using various non drug techniques.
Psychologists are not medically trained but will have had a graduate training in psychology followed by professionally supervised practice.
Healthcare assistants can work within hospital or community settings under the guidance of a qualified healthcare professional. The role can be very varied depending upon the area in which the person is employed.
Working alongside nurses, for example, they may sometimes be known as nursing auxiliaries or auxiliary nurses. Healthcare assistants also work along side qualified midwives in maternity services.
The types of duties include the following:
- washing and dressing
- helping people to mobilise
- bed making
- generally assisting with patients’ overall comfort
- monitoring patients’ conditions by taking temperatures, pulse, respiration and weight (Obs).
Occupational Therapists assess and assist patients to return to participation in normal life and activities.