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Legal risk on Read code changes

GPs are wasting practice staff time and could face future legal problems by substituting new Read codes for old in their medical records.

GP negotiators and medical defence bodies have warned against the move after LMCs reported many GPs were altering records as part of preparations for the new contract.

Dr Stephanie Bown, head of medical services at the Medical Protection Society, said altering medical notes after the event would 'shoot GPs' credibility to pieces' in any later investigation.

'If there is a dispute between doctor and patient about what happened at a consultation the facts of the medical record will be of great assistance,' she said

'If it turns out they are written later ­ perhaps after the doctor became aware something went wrong ­ a question is raised as to whether they were altered in anticipation of a problem. It shoots their credibility to pieces.'

She stressed any changes to records should only add data and be clearly marked by the date and time of the change.

GPC negotiator Dr Laurence Buckman said making changes was 'a waste of effort' as data will not be used to score quality points until January. Software upgrades will also automatically link old codes with new ones.

GPs should leave the choice of code to their computer, even if they know which one they think is right, he added.

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