An inspector calls
There may be occasions when a GP legitimately needs to amend a patient's records. If so, the amendment must be done in the proper way, says Dr Nicholas Norwell
A medical record is an essential clinical tool, albeit a basic one. It provides a clear and accurate picture of a patient's care and treatment and facilitates communication between health care professionals.
Anyone who has received a complaint or allegation of negligence will have had first-hand experience of the importance of the medical records in helping resolve a patient's dissatisfaction.
The GMC, in paragraph 3 of Good Medical Practice, states that doctors should 'keep clear, accurate, legible and contemporaneous medical records which report the relevant clinical findings, the decisions made, and any information given to patients and any drugs or treatments prescribed'.
So it makes sense then to make a record at the time of a consultation, or as soon as possible afterwards.
Fresh in the mind
What makes a record of unique evidential value is the fact that the details of the case are noted contemporaneously while the consultation, incident or phone call is fresh in your mind and before your memory has been distorted by the passage of time or the knowledge of subsequent events,
There may, however, be times when the record will need to be altered, amended or explained.
Examples of situations where you may need to amend a record include:
·An entry put in the wrong patient's
notes for example patients with the same name.
·A patient asking for a correction of an inaccuracy, such as a date of birth, an allergy or a past medical incident. In these circumstances the record should be amended only if the doctor is absolutely sure the information is wrong and then only in the manner recommended by the MDU (see box below left). The incorrect information should still be obvious, as doctors may have acted on that information in the past.
·A patient's name changing as a result of marriage, deed poll or adoption.
When you amend, update or alter a record, it is advisable to follow a few simple steps to ensure that it is obvious to anyone reviewing the record at a later date who made the alteration, when they made it, and why. In other words it is important to ensure that there is an identifiable audit trail.
Not only is it a simple matter of good patient care to note the date and time of an entry, but you may also need to refer back to it for medicolegal purposes years later.
With computer records the audit trail is usually automatic, but with paper records you will need to ensure that it is traceable.
Discovering factual errors
If you discover a factual error in the notes you should inform the patient and explain any possible implications for their health or treatment. Apologise for the error and explain that the notes will be amended in the proper way. It is also sensible to add a note that you explained the error to the patient.
Under the Data Protection Act 1998, patients can ask for their records to be amended and the Act puts an obligation on doctors who are data users to store accurate, up-to-date information.
There may be circumstances where you should not agree to a patient's request for an amendment. For example, a patient may ask for removal of a sensitive incident such as a suicide attempt, a termination of pregnancy or a psychiatric episode. There may also be cases where a patient disagrees with the 'flavour' of an entry, not disputing its basic truth.
In this case they can add their own account of the incident that could sit side by side with the doctor's. The Data Protection Act states that the information held 'Shall be adequate, relevant and not excessive'.
The MDU's advice when amending records
·Medical notes must never be overwritten or inked out and computer forms must never be erased or deleted.
·Hard copy errors should be scored out with a single line so that the original writing is still visible and the correct entry written alongside with the time, date and your signature.
·Any additions should be separately dated, timed and signed. Never try to insert new pages of notes.
·If making an entry or correction to a computer record you should 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 to the reader that an alteration has been made.
A divorced mother asked her GP to amend her child's record to carry their new surname.
The GP rang the MDU to ask if they should just go ahead and change it or if they should seek documentation from the parent.
The MDU advised that while patients do not necessarily need
to go through any prescribed legal procedure to informally change their own names, where children are involved this can be an area of particular sensitivity.
The MDU advised the GP that it was best to ensure that all those with parental responsibility were happy about the name change.
Parents married at the time of the child's birth automatically have parental responsibility. If not, the mother automatically has parental responsibility and the father can acquire it in a number of ways such as through a statutory declaration or court order.
If the father had parental responsibility and objected then the practice was advised not to change the name until the parents had resolved the situation, legally
Nicholas Norwell is an MDU medicolegal adviser
The cases mentioned are fictitious, but based on cases from MDU files doctors with specific concerns are advised to contact their medical defence organisation for advice