Initially it would be advisable to see the patient to ascertain in more detail why the patient wishes this information removed from his notes. You should take the opportunity to reassure the patient of your confidentiality obligations and the limited access others would have to his notes without his consent.
Health professionals have a legal obligation to keep accurate and up to date information in medical records but patients do have the right under the Data Protection Act to request that a factual inaccuracy is deleted or changed. However you should only comply with this request if it is valid.
Good communication is required to explain that the information may be ‘opinion' rather than ‘fact', however previous opinions are important in understanding previous care decisions. In this case, unless you were the treating physician at the time of the entry it is unlikely that you can state that the entry is inaccurate.
If you decide the objection is valid you need to add an amendment, sign and date it. There are only rare examples when an entry can be deleted from a medical record. Even if you agree with the patient that an entry can be removed you would need to explain that electronic records cannot be fully deleted because of the necessity to maintain an audit trail.
The patient may also need to be informed of any potential risk in removing an entry. A viable alternative to the patient may be the option of adding an addendum to the notes stating the patient's objection to the entry. More detailed guidance is available from the National Information Governance Board for Health and Social Care [1].
Dr Sarah Townley is a medicolegal adviser at the Medical Protection Society
Medical records
