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Patients given legal right to have ‘factual errors’ corrected in medical records

Patients have the right to ask their GP to correct any factual errors they see in their medical records, according to the new NHS Constitution.

In the Government’s response to its consultation on the NHS Constitution, they re-asserted patients’ right to access their health records, and added that they have the right to ‘have any factual inaccuracies corrected’.

The accompanying handbook clarified that this did not give the patient the right to change a clinical opinion and that if a GP disagreed there was an error then the patient’s disagreement should be written into their notes.

The news follows comments made by Dame Fiona Caldicott, who is leading the Government’s information governance review. Last November she said patients should be able to amend errors in their records, but should not be able to change their medical histories.

The changes to the NHS Constitution come as the Government began to implement its target for GP practices to offer patients access to full patient records, appointment booking and test results by 2015, with a new DES beginning this year.

The handbook said: ‘You have the right to have any factual inaccuracies corrected. Ask your health professional about amending your records if you believe they contain a factual error.’

It added: ‘There is no obligation to amend professional opinion, however sometimes it is difficult to distinguish between fact and opinion. Where you and the health professional cannot agree on whether the information in question is accurate you can ask that a statement is included to set out that the accuracy of the information is disputed by you.’

They added that they removed a statement which said that health records ‘will always be used to manage your treatment in your best interest’ as this could sound ‘paternalistic’.

The handbook clarified that there are only a few exceptions where patients should be denied access to their records, such as where the information includes details about another person, or where the information may be harmful, for example, where serious mental illness means the patient may be a risk to themselves.

Elsewhere in their response, the Government formally enshrined doctors’ duty to promote healthier lifestyles in the constitution, despite concerns voiced during the consultation process that this could lead to performance management.

The handbook said GPs should provide brief lifestyle advice and/or refer patients to an appropriate service to help patients understand how they can improve their health and wellbeing and reduce health inequalities. They should understand and respect a patient’s feelings towards discussing their lifestyle behaviours during this process.

However, the handbook fell short of asking GPs to promote healthier lifestyles every time they see a patient, instead saying they should identify appropriate opportunities ‘as they arise’.

The handbook said: ‘Making Every Contact Count is an opportunity to improve patient care, treatment and outcomes and help people live well for longer.’