Medico-legal - Alterations to medical records

Patients have rights regarding their medical records, but there are exceptions.

Patients request changes to their medical records for a number of reasons, but they are usually specific
Patients request changes to their medical records for a number of reasons, but they are usually specific

GPs come into contact with medical records on a daily basis. Now that there is an increasing emphasis on cross-team working, information in records has become more diverse than was traditionally the case.

Patients have had a right of access to their own records for nearly 20 years and the use of electronic records is likely to make access easier in the future.

It is becoming more common for patients to raise concerns about the contents of their records, and ask for amendments or even deletions to be made.

Why patients want amends
The reasons patients want changes made are usually specific:

  • Factual inaccuracy.
  • The patient wants part of the record suppressing: most patients will not want highly sensitive material shared or accessed without their consent, so they may try to have parts of the record deleted, and may want all trace of the deletion removed.
  • 'Fact' versus 'opinion': patients may be concerned when there are conflicting opinions expressed in their records, or where the ultimate diagnosis differs from the original one.
  • Third party information: this is information given by, or concerning, another person, but not a professional involved in the patient's care. Usually, the Data Protection Act 1998 would not allow this material to be revealed to the patient without the consent of the third party.

In any of these circumstances patients may be unhappy with, or dispute the accuracy of, entries in their records and they may ask for alterations. So, what should doctors do?

Legal guidance
The GMC guidance Good Medical Practice states that doctors must keep clear, accurate and legible records, reporting clinical findings, decisions, details given to patients, and any drugs prescribed or other investigation or treatment.

You must also make records at the same time as the events you are recording or as soon as possible afterwards.

Most doctors also have contractual obligations to keep records. In the case of GPs, the GMS contract stipulates that practices should keep 'adequate records of its attendance on and treatment of its patients'.

Failure to follow these guidelines, particularly making inappropriate alterations or additions to records can result in difficulties for the doctor.

The Data Protection Act 1998 allows patients certain rights.

The Data Protection Act

Under the Data Protection Act patients have the following rights:

  • Access to their records.
  • That information held about them is accurate and, where appropriate, up to date.
  • To have mistakes in the record put right.
  • To request that an opinion which is factually incorrect is modified or removed from the record.
  • To request that the processing of information is stopped if it is causing significant harm or distress.

However, it does not give them the right to insist that a record be kept in a specific form (for example, paper rather than electronic) or that they be stored in a specific place (although they must be stored securely).

It is generally accepted that one of the main purposes of the medical record is to enable you or someone else to reconstruct the essential parts of each patient contact.

Notes need to be comprehensive enough to allow a colleague to carry on where you left off and to preserve the decision making process.

The National Information Governance Board for Health and Social Care (NIGB) has produced detailed guidance on this topic (see resource below).

If a patient complains
If a patient objects or complains about an entry in their records, first discuss the patient's concerns with them and record this concern.

If it is agreed that information is factually incorrect, add an agreed correction together with a note explaining what was corrected, by whom and when.

Explain that 'corrected' does not mean deleted without trace. A manual note should have a single line drawn through the entry, so as to leave it still legible. Also explain that an alteration to an electronic record is always preserved (together with the original entry) as part of the audit trail.

If an opinion is the subject of a complaint, explain that an opinion is not incorrect just because someone, including another professional, disagrees with it.

Opinions can change or vary with time, and keeping a record of previous opinions (even if they were ultimately shown to be wrong) can be vital to understanding the diagnostic and therapeutic process.

If, after discussion and following the steps above, the patient remains dissatisfied, add a note explaining the patient's remaining concerns and offer them the option of adding an addendum of their own.

Rarely, there may be circumstances when, after a full risk assessment, it will be agreed that information will be completely removed from a paper record leaving no trace that it was ever there.

You should make sure you discuss this fully with the patient, and seek advice from your Caldicott guardian or medical defence organisation before making a decision.

Finally, if the patient remains dissatisfied, explain that they can use the complaints process, and provide them with detail of how to do so.

Normally this will be the NHS complaints procedure, but patients may also approach the Information Commissioner's Office, though the commissioner will normally only get involved after the patient has given the organisation concerned the opportunity to put things right.

  • Dr Clements is head of medical services at the Medical Protection Society

Learning points

Medical records
1. Patients have a right to access their own records.

2. GPs are obliged by the GMS contract to keep patient records.

3. Any notes need to be comprehensive enough for a colleague to understand if they were taking over a patient's care.

Resources

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