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Correcting Medical Records

The surgery takes patient confidentiality very seriously, however from time to time there may be a genuine mistake on a patient’s medical record, whether that has occurred during the patient’s time with the surgery or before they registered with the surgery. Patients can request a rectification at any point, to any member of staff, whether verbally or in writing. There are no fees charged.

All mistakes relating to medical notes could be very serious and will be treated as such. Any incident will be reported to the Information Governance (IG) lead, who may need to report such incidents to the Information Commissioners Office (ICO), Care Quality Commission (CQC) and other relevant bodies. All errors will be rectified and corrected as soon as they come to light or within a reasonable timeframe thereafter.

Errors can be split broadly in to 3 categories;

Factually Inaccurate Entry – Sometimes, despite policies in place to prevent it, an entry will be made on the incorrect patient. This could be a clinical letter, a consultation or a simple coded entry. These incidents should be immediately reported to the surgery who will remove the incorrect entry and ensure the problem is rectified. This cannot be actioned by reception staff and must be completed by a member of the management team.

Incorrect-diagnosis – Sometimes patients will disagree with a diagnosis on their record or may have a problem recorded inaccurately. If this occurs the patient will need to make an appointment to discuss this problem with the Clinician who added the incorrect code or miss-diagnosis. If it is not possible to see the Clinician who added the entry, then the patient should see the Clinician who has seen them the most often or recent.

Disputed information – Patients may seek correction of information they believe is inaccurate. The Clinician is not obliged to accept the patient’s opinion, but must ensure that the notes indicate the patient’s view. There are strict NHS England guidelines that state information which is clinically relevant must not be deleted from medical records. If this occurs the patient will need to make an appointment to discuss this problem with the Clinician who added the disputed information. If it is not possible to see the Clinician who added the entry, then the patient should see the Clinician who has seen them the most often or recent.

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