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The correct way to amend your records

Medical records are of unique evidential value, so take care if you need to amend them, advises Dr Nicholas Norwell

Medical records are of unique evidential value, so take care if you need to amend them, advises Dr Nicholas Norwell

A medical record is a basic but essential clinical tool. It provides a clear and accurate picture of a patient's care and treatment and helps communication between health care professionals. Anyone who has received a complaint or allegation of negligence will know the importance of the medical records.

The GMC, in paragraph 3 of Good Medical Practice, says 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'.

It makes sense to make a record at the time of a consultation, or as soon as possible afterwards. It is the fact that the details are noted contemporaneously, while the consultation is fresh in your mind and before the knowledge of subsequent events, that makes a record of unique evidential value.

There may be times when the record will need to be amended. Examples include:

• an entry put in the wrong patient's notes, for example patients with the same name

• a patient's name changing as a result of marriage, deed poll or adoption

• 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 described below. The incorrect information should still be obvious, as doctors may have acted on that information in the past.

When you alter a record, follow a few simple steps to ensure that it is obvious who made the alteration, when and why.

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 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 it is traceable.

The MDU's advice when amending records can be summarised as:

• 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.

If you discover a factual error in the notes you should inform the patient and explain any possible implications. Apologise and explain that the notes will be amended in the proper way. Also 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 if a patient asks for removal of a 'sensitive' incident, such as a suicide attempt or a psychiatric episode.

If a patient disagrees with the 'flavour' of an entry, not disputing its basic truth, they can add their own account that could sit side by side with the doctor's.

Nicholas Norwell is an MDU medicolegal adviser

Case example

A GP saw a new patient and, having taken a medical history, noticed some errors in the medical notes. The date the patient said she had had a termination of pregnancy did not correlate with the date recorded in the notes. In addition, the patient listed a number of medications she had been prescribed for migraine, but not all of these were listed in the records. The GP rang the MDU to ask if he should amend the record or seek further evidence from the patient first.

The MDU adviser suggested the GP see the patient again and try to establish the medical facts as accurately as possible, using, for example, objective evidence such as hospital letters, or even perhaps writing to the hospital/doctors concerned (with the patient's consent).

It could be that the omission of the migraine treatment was a simple oversight on the part of the previous GP; if so, the fact that the patient had been taking the treatment for a certain period of time should be accurately reflected in the records. Any alterations or deletions should be made as described above.

In short, the doctor and patient should work together to make sure the record is as accurate and up to date as possible.

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