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One of my patients has just died from a heart attack in hospital. I examined him thoroughly three hours ago but only made a brief note of the consultation, as I didn't have time to write up a full note - can I update the record after the event?
Records are primarily intended to support patient care and should authentically represent each and every consultation (including by telephone). They form the basis of good communication about the patient, between doctor and doctor, or between a doctor and other members of the health care team. However, medical records may sometimes need to be amended.
Any change should be clearly documented either electronically or in writing to show the date of the amendment and the name of the individual making the change – in other words that there is an identifiable audit trail. It must remain possible to retrieve the original entry. Hard copy errors should be scored out with a single line so that the original writing is still visible and the correct entry written alongside with the time, date and your signature.
Medical notes must never be overwritten or inked out and computer forms must never be erased or deleted. Any additions should be separately dated, timed and signed. Never try to insert new pages of notes. The GMC, in paragraph 19 of Good Medical Practice (2013), states that 'Documents you make to formally record your work must be clear, accurate and legible. You should make records at the same time as the events you are recording or as soon as possible afterwards.' It goes on to say that clinical records should include 'relevant clinical findings, the decision made and actions agreed, the information given to patients, any drugs prescribed or other investigation or treatment, who is making the record and when.' 'Tampering' with records has led to GMC investigations and the MDU has had to settle claims when what might otherwise be quite defensible clinical decisions and actions have not been supported by adequate records.
When adding your more detailed note to the patient's record you should include your name, the date and time of your added note, your findings on examination and an explanation as to why these were not recorded at the time.
This page was correct at publication on . Any guidance is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.