Medical records are key to providing a clear and accurate picture of a patient's care and treatment, and underpin the delivery of safe healthcare. If a patient asks for their record to be amended, GPs need to consider the request carefully.
Requests to alter or delete an entry in a patient's records are a frequent subject for GPs calling the MDU's advice line wanting clarification of their legal and ethical obligations.
Doctors have a legal and professional duty to keep accurate and up-to-date records. Under the Data Protection Act 1998, patients have the right to ask for their records to be amended.
The GMC also requires doctors to 'report the relevant clinical findings, the decisions made, and any information given to patients and any drugs or treatment prescribed' in the records - see the GMC's Good Medical Practice, 2006, paragraph 3.
If you decide it is necessary to amend or update a record, ensure that it is obvious who made the addition as well as when and why, because there should be an identifiable audit trail.
Noting the date and time, and whether it is a correction or a new entry is not just a matter of good patient care: you may need to refer back to it for medico-legal purposes at some point - possibly years later.
Computer records usually have an automatic audit trial. Paper records need to be clearly and legibly written, signed and dated. As well as following DH advice in Guidance for Access to Healthcare Records Requests (February 2010), the MDU advises GPs that:
- Medical notes must never be overwritten or inked out and computer records should not be completely deleted.
- Hard copy errors should be scored out with a single line so that the original writing is still visible, and the correct entry should be written alongside with the time, date and your signature.
- Any additions should be separately dated, timed and signed.
- If making an entry or correction to a computer record, ensure there is an audit trail identifying the date and time of the change and the person who made it.
- It should be immediately obvious that an amendment has been made.
- QOF codes form part of the record so need to be an accurate description of the patient's condition/treatment.
- If you discover a factual error, you should inform the patient and explain any possible implications for their health or treatment. Apologise and explain that the records will be amended. You may wish to add a note that you have explained the error to the patient.
- If you do not agree with a request for an amendment, you can explain to the patient that it is open to them to add a statement that they disagree with the content.
See the two examples below, they are fictitious but based on cases from the MDU's files.
|WRONG PATIENT'S NOTES|
A patient discovers that information relating to another patient registered at the practice with the same name has been entered erroneously into his medical record. He asks for the entry to be deleted.
After getting advice from the MDU, the GP concerned apologises and explains to the patient that the notes will be amended. The GP does not completely erase or delete the incorrect details from the computer record but makes a clear entry in the record, explaining the error. The GP dates, times the correction and clearly signs the correction to show that he made it.
A patient loses consciousness suddenly and is seen by an A&E doctor who records that she may have had an epileptic fit.
Later on, a neurologist sees the patient and diagnoses a vasovagal attack. The patient, aware that a summary of her A&E attendance has been sent to her GP, asks the GP to delete the epilepsy diagnosis from her medical record.
She is concerned that the record of possible epilepsy could have adverse implications - for example, if she applies for medical insurance. The MDU advises the GP that the Data Protection Act could not be used to challenge a professional opinion, on the basis that it is inaccurate, just because someone, even another clinician, has a different opinion.
If, however, the opinion contains incorrect factual information it can be challenged and the GP can record the challenge alongside the opinion. It is important to keep the original entry because only the entire medical record will adequately show a medical history, the record of care or why a course of action was taken.
In this situation, the GP adds a note explaining the epilepsy diagnosis is considered incorrect, but does not delete the A&E doctor's entry.
- Dr Phillips is a medico-legal adviser at the Medical Defence Union, www.the-mdu.com