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Implications of making changes to Read codes

Quality points earnings will depend on the right Read codes ­ Dr Sally Barnard of the Medical Defence Union discusses legal implications of amending notes

Imagine the following scenario. A patient comes to see you with chest pain. You make a differential diagnosis of angina and enter a Read code on his computer notes to this effect. You then refer the patient to a fast-access chest pain clinic. Fortunately it turns out he only has reflux oesophagitis. To ensure the patient's record remains accurate, and as the practice's quality points earnings will depend on the right codes being entered, the Read code will need to be updated. But would you be on safe legal ground to simply strike the code out and alter it? After all this is altering a legal document ­ the patient's notes.

The main purpose of medical records is to give a clear and accurate picture of the patient's care and treatment to ensure they receive the best possible clinical care. Any other functions, such as to protect the doctors against compensation claims or to ensure the accurate payment of practice quality fees, are secondary.

After all, the quality framework is all about providing a high-quality service. A computer medical record is like any other medical record. It is a narrative history of the patient's symptoms, diagnosis, care and treatment. And of course all these things are subject to change over time. As such, any clinician having a role in this patient's management must be able to look at the notes and get a comprehensive picture of his history, treatment and care.

The GMC's booklet Good Medical Practice (www.gmc-uk.org) says doctors must keep 'clear, accurate, legible and contemporaneous patient records which report the relevant clinical findings, the decisions made, the information given to patients and any drugs or other treatments prescribed'.

The most important consideration in our example here is that the patient is informed that the condition is reflux rather than coronary in nature and that by updating the record other GPs in the practice can see this at a glance.

Once that is done you can amend the computer record and insert the suitable Read code making sure you have made a signed and dated entry on the record stating this correction has been made. All computer records should have an audit trail and it will be clear from this when and where changes are made.

The Joint Computing Group of the GPC and the RCGP had published Good Practice Guidelines for General Practice Electronic Patient Records which give helpful advice (www.doh.gov.uk/pricare/ computing/Goodpracticeguidelineselectronicrecords0903.pdf).

Of course, perhaps a more common scenario might be when the situation used in this example is reversed and the patient with suspected reflux is referred and does in fact have angina. But the principles are the same ­ the computer record must be an accurate reflection of the patient's treatment and care.

As more GPs switch to computerised records, the most important medicolegal issue that arises from their use is the accuracy of the data they contain. In a recent MDU survey 39 per cent of members said they failed to enter the same level of information on computerised records as in paper medical records.

Sally Barnard is a medicolegal adviser with the Medical Defence Union in London

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