Medical Records - Alterations
We are often asked under what circumstances, and how medical records may be altered. This article condenses advice from the Medical Defense Organisations and the GMC:
- Medical notes must never be overwritten or inked out, and computer records should not be completely deleted.
- Hard copy errors should be scored out with a single line, so that the original writing is still visible, and the correct entry should be written alongside, with the time and date and your signature.
- Any additions should be separately dated, timed and signed.
- If making an entry or correction to a computer record, 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 that an amendment has been made.
- QoF codes form part of the record so need to be an accurate description of the patient’s condition or treatment.
- If you discover a factual error you should inform the patient and explain any implications for their health or treatment. Apologise and explain that the records will be amended. You may wish to add a note that you have explained the error to the patient.
- Occasionally, there may be circumstances, after a full risk assessment, that it my be agreed that information will be removed from a paper record. this should be discuss with the patient and guidance sought from your Caldicott Guardian and/or MDU before making a decision.
- If you do not agree with a request for an amendment, you can explain to the patient that they may add a statement that they disagree with some part of the content. If the patient is still unhappy, they may follow the normal complaints procedure or approach the Information Commissioner's Office.
The MDU also have a wealth of information on amendments which may be of help please click the link