Can you amend medical records? Hannah Egan discusses some different scenarios.
It is important for a patient to give an honest account of their concerns and medical history during a clinical consultation.
And it is equally important for a clinician to document in the medical record an accurate summary of the information conveyed so this can be reviewed and considered as part of the patient’s medical history in the future.
But what happens when a patient later learns about the extent of the information written in their records and requests amendments to reflect their interpretation of the consultation?
There are a number of reasons why a patient may request a doctor amends their medical record – for example:
- To dispute a diagnosis
- To request that the record of a provisional diagnosis is removed and replaced with the confirmative diagnosis which was later made
- To dispute the relevance of an entry
The question facing the healthcare professional, who is the data controller for the information stored, is: can I amend the medical record?
UK General Data Protection Regulation
Under the UK General Data Protection Regulation (GDPR), individuals are afforded the right for inaccurate information which is held about them to be amended. The Information Commissioner’s Office (ICO) has discussed this further in its guidance on the right to rectification:
‘Under Article 16 of the UK GDPR, individuals have the right to have inaccurate personal data rectified. An individual may also be able to have incomplete personal data completed – although this will depend on the purposes for the processing. This may involve providing a supplementary statement to the incomplete data.’
In a similar vein, UK GDPR also provides individuals with the right to have personal data erased – which is also known as the right to be forgotten.
However, it is important to highlight that while individuals generally have a right for inaccurate information which is held about them to be amended, it does not provide a patient with the right for factually accurate information within a medical record to be amended.
Nor does it afford a patient with the right to request that an entry which reflects medical opinion is amended.
Factual inaccuracies
When an independent clinician receives a request from a patient for their medical record to be amended, or for certain information to be removed, it is important that they, as the data controller, consider the request carefully to determine whether the contended information is factually accurate.
As an example, consider a situation where a patient has attended a consultation about a recently sustained left-sided fracture; for example, left radius. But the clinician accidently notes the record to detail that the patient has suffered a right-sided fracture.
Given the apparent and unquestionable lack of ambiguity, the clinician may reasonably conclude that an honest error has been made in the documented entry. Because the information detailed is inaccurate, the clinician feels justified in amending the medical record accordingly.
Here, the clinician must ensure that an audit trail would be able to clearly confirm why the amendment within the record has been made. Crucially, in this scenario, the disputed entry is unequivocally inaccurate.
Now consider a scenario where a patient asserts that they disclosed suffering from knee pain for a number of months during a consultation, whereas the records reflect that the pain had been felt for several weeks.
In this instance, it is far more challenging to conclude with any certainty that there is a factual inaccuracy within the records given that the patient is disputing, and is solely relying upon, a conversation which took place in private between two individuals.
The patient’s perspective
Therefore, the clinician in this instance may conclude they cannot be certain a factual inaccuracy has been included within the records and reject the request for the entry to be amended.
This does not mean an addition cannot be added to the records to reflect the patient’s perspective.
When a clinician feels it would be inappropriate to make the requested amendments, then it is possible to add an addendum to the record reflecting the date the supplementary note is included.
The benefit of an addendum is that it allows a patient’s opinion of an entry to be reflected, while ensuring the content of the original entry is not amended.
Outdated diagnosis
There may also be circumstances where a patient approaches a doctor to request that a medical opinion detailed within the record is amended because it reflects a perceived outdated diagnosis.
During an initial consultation to discuss a health issue, it is often not possible to confirm with certainty the specific condition a patient is suffering from, as further investigations may be required.
Therefore, a clinician may document a provisional diagnosis within the records while investigations are ongoing. If the results of the investigations return to confirm a differing diagnosis to one which the clinician was initially considering, this does not mean the provisional diagnosis documented in the records is inaccurate.
Rather, the entry reflects the clinician’s medical opinion based on the information available to them at the time.
It is, of course, possible that a patient may contend the importance of maintaining reference to a provisional diagnosis, when they have later received a confirmative diagnosis.
But there is an undisputed benefit of continuing to include this information because it allows clinicians who are involved in the patient’s care in the future to be aware of all possible diagnoses considered previously.
In turn, this will assist the treating clinician in determining whether previous diagnoses considered are of any relevance to the clinical care they then provide to the patient moving forwards.
Relevance
A further avenue a patient may explore relating to amending their medical record is to dispute the clinical relevance of the information which has been recorded.
There may be instances where a clinician makes reference to the appearance of a patient when they present for a consultation, or provides comment on a patient’s living environment, for example.
When a patient learns this information has been entered into their records, they may understandably have questions and concerns about the reason.
It would be important to consider if the information bares clinical relevance and, if so, this should not be removed from the record.
These sorts of entries may naturally be subjective in reflecting the clinician’s perspective and opinion and it would be inappropriate to amend a record that accurately reflects a medical opinion or a record and is not clearly and undisputedly inaccurate.
This would not prevent a clinician from explaining to a patient why they recorded such detail and it is possible that explaining the rationale for the information recorded may assist in a dispute about the entry in any event.
Relevant to clinical care
It is essential for a clinician to ensure a patient’s medical record only contains information justifiably relevant to the person’s future clinical care. Any other information should be stored separately to the medical record.
An example of this could be a subject access request, given that this may not be information relevant to the patient’s care. But the decision of clinical relevance is something for a clinician to consider and justify on an individual basis.
UK GDPR affords individuals the right for inaccurate information held about them to be amended and also provides individuals with the right to have personal data erased.
But this does not extend to information contained in a medical record which is factually accurate and reflects clinical opinion.
As data controllers, independent practitioners should always consider a medical record’s factual accuracy, as it would be inappropriate to amend any information which is not clearly and undoubtedly factually inaccurate.
If in doubt, always contact your defence organisation for advice.
Hannah Egan is case manager at Medical Protection.
