Practice dilemma: Records change request
A patient has asked her GP for a copy of her medical records as she believes that during a recent visit there was an inaccurate note on her health. How should you share the information with her and are you obliged to change her records?
It is becoming more common for patients to raise concerns about the content of their medical records and, under the Data Protection Act 1998, they have the right to access a copy. The act preserves the right of access by patients to any personal information held by a practice or healthcare body.
A health record is defined by the Data Protection Act as any record that consists of information relating to physical or mental health or condition of an individual and has been made by or on behalf of a health professional in connection with the care of that individual.
Doctors should always remember patients have a legal right to see their records. Therefore, notes in records should be neutral and non-judgmental as anything recorded – no matter where it is stored – can be recoverable under the act. Records should also be clear, accurate, legible and up to date.
Patients can gain access to their records via a subject access request. These requests should be made in writing to the GP or organisation holding the health records. It is good practice to record all requests for information and you should track these through to completion.
Once these records have been accessed by the patient, they have the right to ask for changes to be made. These can include correcting simple errors such as a wrongly recorded address. However, there may also be fundamental conflicts over clinical content.
If, after the patient has looked over their medical records, they think information is inaccurate, the patient should discuss this with their GP. If the patient is disputing the GP's professional opinion or disagrees with what is recorded in the notes and the doctor is unwilling to amend the entry, the patient can include a statement in the records to the effect that they disagree.
If doctor and patient come to an agreement that the information is factually inaccurate, then the record should be amended. Amendments should be clear and legible and include time, date and a signature of the individual making the change. Computer records should also allow for an audit trail identifying the date and time of any changes and the person responsible.
The patient can make a complaint through NHS complaints procedures or the Information Commissioner's Office, which handles cases involving compliance with the Data Protection Act, if they are unhappy with the content of their medical records or the way the practice has dealt with their request that changes are made.
Patients have never been as informed as they are today on health matters. Government plans for patients to have full online access to their medical records by 2015 may lead to a further increase in requests to alter records in the future. Therefore, it is important to ensure patient records are accurate and clear.
Transparency is the key to ensure any disputes regarding healthcare records can be dealt with to the satisfaction of doctor and patient.
Dr Anthea Martin is a senior medical adviser for MDDUS