Changing the record

A patient went to see her GP because she had been feeling anxious and depressed following the breakdown of her marriage. The GP was new to the practice, so he looked back through the clinical record and noticed the patient had attempted suicide five years ago after an argument with her husband.

However, when he asked the patient about this, she became angry and denied that she had ever tried to kill herself. She demanded that the GP remove this entry from the record because she had a legal right to correct inaccurate information and it would cause doctors to judge her unfairly.

The GP sought advice from the practice’s data protection officer. She explained that as a data subject, the patient had the right to correct data if it is factually inaccurate or incomplete, such as a misspelt name, but this does not extend to clinical opinions.

At her suggestion, the GP went back to the patient to explain the situation and suggest an alternative course of making an additional note that she disagreed with the content. He also reassured her that he had made no judgment about her based on the record. He was only interested in whether she would benefit from mental health support.

The patient was disappointed but accepted his suggestion. She also agreed to the GP’s proposal to refer her to a counsellor.

MDU advice

• Records must never be overwritten, inked out or deleted. Factual errors can be corrected but it must be immediately obvious what has been changed, who made the amendment and the time and date it was changed.
• If you forget to include something significant in your records, you can make an additional note, but it should be clear when you added the information and why. This way your honesty cannot be called into question.
• Familiarise yourself with your practice’s data protection policies and procedures so you know how to manage subject access requests, report a data breach and respond to queries. You should also know the name of your practice’s data protection officer so you can seek further advice if needed.
  MDU advice.