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How Do You Correct Your Medical Records?

How Do You Correct Your Medical Records?

In Good Medical Practice 2006, the General Medical Council (GMC) states that doctors should “keep clear, accurate and legible records, reporting the relevant clinical findings, the decisions made, the information given to patients, and any drugs prescribed or other investigation or treatment” and further that they should “make records at the same time as the events you are recording or as soon as possible afterwards.”

Unfortunately, this is not always the case and sometimes the medical records either do not reflect accurately what happened between the doctor and patient, or they are completely wrong and/or inaccurate.

In addition to the potential impact upon your healthcare and outcomes, in the event of legal proceedings by a patient the information held in the medical records may become evidence and any inaccuracies in the records could give rise to serious consequences; for example if a patient is shown not to have attended a medical appointment when in fact they did, insurers are bound to argue that the claimant has not mitigated their losses by seeking the treatment which was available to them and could try to reduce any compensation accordingly.

The Data Protection Act 1998 (regulated and enforced by the Office of the Information Commissioner), gives the right to access and see personal information about you held by public authorities and private bodies, including your medical records. Since patients have been able to access their medical records, they have also been able to request amendments and to have any objections recorded in their medical records.

However, while patients have the right to ‘have any factual inaccuracies corrected’, this does not give them the right to change clinical opinion. It is also important to note that a GP or hospital trust cannot delete any information in your records, it can only be amended.

The easiest way to ensure that your GP records are amended is to write to the GP practice setting out the inaccuracies and requesting that an amendment is placed into your medical records. Alternatively you could arrange a meeting with your GP and/or practice manager to discuss the inaccuracies.

Remember, there is no obligation upon practitioners to amend professional opinion although sometimes it is difficult to distinguish between fact and opinion. But if there is a lack of agreement on whether the information in question is accurate you can request that a statement is included in your records stating that the accuracy of the information is disputed by you.

If the error and/or inaccurate information are contained within your hospital records, you can again write to the hospital trust and request that the inaccurate information is amended. It is important to note that once again the hospital trust cannot delete the information, it can only insert any amendments. If the hospital and the doctor concerned do not agree with your suggested amendments your objections about their opinion can be noted and put into your file.

If either your GP or hospital trust is unwilling to help with regard to amending your medical records a formal complaint should be made. If this fails to resolve the matter, a direct appeal to the Information Commissioner should be considered.

For further information and advice about pursuing a claim for clinical negligence please contact Senior Partner Shaun Burke on 01325 466461 or email shaun.burke@close-thornton.co.uk

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