Dr Zaid Al-Najjar, medicolegal adviser at Medical Protection advises:
Some patients may not realise that the majority of what they tell a GP will be recorded in their medical record in some form or another. Patients can therefore become upset when they find out that particularly sensitive or personal information has been recorded by a GP and can ask for it to be removed.
It might be helpful to explain to the patient that a complete and comprehensive medical record is essential for continuity of good medical care. The GMC advises ‘Documents you make (including clinical records) to formally record your work must be clear, accurate and legible. You should make records at the same time as the events you are recording or as soon as possible afterwards’.
You should also reassure them that their details are secure as you are bound not only by your professional duty of confidentiality but also by statute – the Data Protection Act 1998.
If the patient still insists on the record being removed, you should establish whether or not the record is factually correct or based on a medical opinion.
If it is factually incorrect you should add a signed and dated supplementary note to correct the inaccuracy and make it clear that the correction is being made at the patient’s request. Avoid deleting the original entry, though. If the patient demands deleting the records, then this should only be done in exceptional cases – and only then in paper records, never electronic.
If the records are factually correct it would be helpful to explain that you are professionally and legally obliged not to alter the record. However, if the patient wishes, a note can be added to the relevant entry to explain to any future readers that the patient disagrees with it (for whatever reason) or that he/she is particularly worried about its existence in the medical record.
This should hopefully reassure the patient that any subsequent reader will note their views and seek specific consent should the notes ever needed to be disclosed in the future, for example to other healthcare professionals or for the purposes of a medical report.
You may also want to make them aware of the Information Commissioner’s Office should they want further information about data privacy.
