Accurate medical records are vital for patient care. They support clinical decision-making and continuity of care, and may also come to your aid if a medico-legal issue arises.
Patients might sometimes ask for changes to be made to their record because it is inaccurate or incomplete, and have the right to do so under Article 16 of the UK General Data Protection Regulation (GDPR).
It's important to take reasonable steps to ensure the data in question is accurate and rectify it if necessary. The reasonable steps will depend on the circumstances, but should include the arguments and evidence provided by the patient who is the data subject, or their representative.
You must respond to such requests within a month, and if possible inform any third parties you have shared data with that it is incorrect. The one month period may be extended by a further two months when the request is complex.
If a clinical opinion turns out to be incorrect after further investigation, it would not be classed as inaccurate data. You are not required to remove clinical opinions but can allow patients to add a note to the records to indicate they disagree with the opinion.
If you refuse a request for rectification, you must explain why to the patient and tell them of their right to complain to the Information Commissioner's Office (ICO) and to a judicial remedy.
Below we look at some anonymised scenarios, based on those raised by MDU members where a request has been made to amend medical records.
A young woman with pelvic pain saw a GP. The GP discussed several potential diagnoses, including pelvic inflammatory disease and chlamydia, and arranged investigations, after which the patient was subsequently found to have endometriosis.
At a later consultation the patient was unhappy to learn that the initial consultation entry included a potential diagnosis of sexually transmitted diseases (STDs). The GP explained this was her working diagnosis, which needed to be documented and ruled out, but because the tests had proved negative the patient wanted these working diagnoses removed.
If information recorded is factually accurate and clinically relevant, then it should stay in the records. This is in line with GMC guidance that clinical records should include relevant findings, decisions made and actions agreed, information given to patients and any investigations or treatment carried out.
It's important for the patient's ongoing care that differential diagnoses accurately represent what was considered and discussed, the steps taken to exclude these, and any results.
It would be inappropriate to remove this information, but depending on what the patient's exact concerns are, an addendum can be added to the records - for example, stating the patient confirmed she was not suffering from a STD and noting they did not think this diagnosis was likely.
Patient's rudeness documented
A patient who had recently registered at a GP practice made a subject access request for their notes spanning the last 10 years. They were considering making a claim against their local NHS hospital trust, and took exception to an entry from many years before which stated "the patient became rude and obnoxious" when they were not sent for the imaging they requested.
The patient contacted the new practice to ask that this was removed because it was untrue. They clearly recalled the consultation and explained that their previous GP had been unhelpful and obstructive.
Requests to amend older records made by another clinician are difficult as you have no way of knowing what actually happened. It also highlights the problem of subjective terms being used to describe an encounter where patient behaviour may have been unacceptable.
It is not advisable to omit that part of the record because the patient doesn't agree with it. However, the patient could approach the previous practice to raise their dissatisfaction with the author of the entry, if they are contactable. Alternatively, the new practice could add an addendum to the records with the patient's account of events.
Rather than describe patient behaviour in the notes using subjective terms such as rude, it is better to document what was said or how a person behaved.
There is an argument that unless the behaviour is clinically relevant it should not be documented in the medical record - in a similar way complaint correspondence is not saved in patient records - so that it doesn't prejudice future care.
Drug use denied
A patient with anxiety and depression admitted excessive alcohol and illegal drug use. They were referred to relevant services. At an appointment a few weeks later, another GP asked whether they had managed to cut down on their use of drugs and alcohol.
The patient denied he had been using drugs or drinking excessively and said his previous statements had been misunderstood. He asked for the information to be removed from the records, adding it could jeopardise an ongoing child custody case.
The original GP clearly recalled the discussion with the patient and felt the records accurately reflected this. As it was clinically relevant and factually accurate, the notes could not be amended.
At the patient's request, an addendum was added that they disagreed with the references to their drug and alcohol use, but the GP had confirmed that their note was correct based on their recollection and their usual practice regarding documentation.
A letter in the wrong records
A patient made a subject access request, and on reviewing their notes discovered a second page of a letter from a psychiatrist which clearly didn't relate to them. It detailed several diagnoses and a lengthy social history about another person, although there was nothing to identify who that person was.
The practice removed the page from the records as it had been included by error and was not clinically relevant to the patient's care.
They were able to identify the correct patient after making contact with the psychiatrist who had signed the letter so the information could be correctly filed.
Request not to record sexual history
A man attended the GP with pain and swelling of his scrotum. The GP suspected epididymo-orchitis and on direct questioning the patient disclosed that they recently had unprotected sex during a one-night stand with a stranger. During the discussion, the patient asked the GP not to record the reference to the sexual encounter. The GP was unsure what to document.
While this is not a record amendment as such because the information is not yet included in the notes, the same principles apply. Even when patients ask that you do not record key information, you cannot ignore information shared with you.
If the information is factually accurate and clinically relevant it should be noted. In this case, the GP explained that the sexual contact was highly relevant to his symptoms and this was why he was being referred to the genitourinary medicine service. As such, she was obliged to record that he'd had unprotected sex with a new partner.
The patient explained that he didn't want his wife to know about the sexual encounter. The risks of unprotected sex and the risk of infecting his wife were discussed. The GP also advised that there would likely be contact tracing undertaken if he was found to be positive for an STD therefore his wife may well be alerted to the fact she had had sexual contact with someone with an STD.
As the above cases demonstrate, requests for record amendments come in a variety of guises and it can be difficult to decide what is accurate or clinically relevant at times. The ICO has detailed guidance on the right to rectification.
We would emphasise that the above cases all relate to patient requests for record rectification which is distinct from when doctors may wish to retrospectively amend/add to records for a variety of reasons. We have issued guidance on this separate topic here but in essence, it is not advisable to add to the records after something has gone wrong even if the intention is to add more context to a consultation.
Any additional details that may be relevant can be documented in the adverse incident statement, complaint letter, coroner's report, etc., making it clear that these specifics are based on the clinician’s recollection.
Remember, if you're an MDU member and have questions on specific cases, you can always contact us for advice.