Amending patient and service user records

Health and care organisations make every effort to keep your records accurate. However, occasionally information may need to be amended about you or your care.

If you think that the health or care information in your records is factually inaccurate, you have a legal right to ask for your records to be amended. For instance, you can ask for your home address to be changed because you moved house. You may also ask for something you feel has been inaccurately recorded, such as a diagnosis, to be corrected. However, it may not be possible to agree to your request.

A request can be made either by speaking to staff or in writing. You may need to provide evidence of the correct details, for example proof of address or change of surname after marriage. The organisation will then consider the request. Where organisations agree to make a change, they should make it as soon as practically possible, but in any event within one month.

Sometimes, you may disagree with information written in your record, but the information could still be factually correct. For example, you may disagree with a diagnosis you were given in the past. Whilst you can still ask the organisation to amend the entry that you feel is inaccurate, an organisation should not change it if the health and care professional believes it is factually correct. There are exceptions to this, for example, where there is a court order.

In cases where all parties agree that the information is inaccurate, it may still be necessary to retain the information. For example, health and care professionals may have taken the information into consideration when making decisions about treatment or care. This information would therefore be needed to justify and explain health and treatment decisions or to audit the quality of care received. You can, however, request for a comment or entry to be made in the record to show that you disagree with the content and what you think it should say.

If you are unhappy with the decision of a health or care organisation to retain information you wish to have deleted there are some steps you can take. In the first instance, you can make a formal complaint through that organisation’s complaints process. If you are unhappy with the outcome of that process then you might consider making a complaint to the Information Commissioner’s Office (ICO) or consider legal action.

Health and care professionals have a legal duty and professional responsibility to keep health and care records accurate and up to date. However, mistakes in record keeping can occasionally happen.

Patients and service users have the right to request for their records to be rectified if they feel inaccurate information is held about them. They may make a request concerning:

• demographic information, for example, wrong date of birth recorded
• their opinion on the health or care information within their record, for example, they may not agree with the initial diagnosis given to them

If you believe that the amendment request concerns health or care information that is factually accurate, you should not amend the record. However, it is good practice to give patients and service users the opportunity to have an entry put into the record to say they do not agree with a particular part and why.

There may be times when information was correct at the time the entry was made but has since changed. For example, there may be an initial working diagnosis which was, at the time of entry, clinically possible, but is later ruled out with a different confirmed diagnosis. Retaining the original diagnosis does not make the record inaccurate, so it is important that this is not amended. It may help when recording information to indicate where something is your opinion rather than a confirmed diagnosis.

If you decide the health or care information in a record is inaccurate and need to amend it, the original entry must not be deleted. It must still be readable. This is because other health and care professionals may have read it and therefore may need to refer to it at a later date to justify their decisions. For paper or handwritten records, you should put a single line through the error, initial it, and put the correct information. Electronic records will vary by system, but all will have an audit trail function, which creates a log of your keystrokes - showing what you typed or added and when. It will also capture any amendments or deletions you make to a record. This is vital to ensure the integrity of the record.

Mistakes should be corrected straightaway, or as soon as possible after you realise a mistake has been made. A full explanation should be provided as to why an entry has been changed retrospectively.

Refer to the ‘further information’ section for guidance on record keeping from professional and defence organisations as well as templates for social care organisations.

Patients and service users have the right to rectification if you hold inaccurate factual information about them. Holding inaccurate information could be seen as a breach of UK GDPR.

Where there is a query from a patient or service user over the accuracy of the health or care information in a record, you should liaise with the health and care professional who entered the information to understand their views. You should seek to determine whether the data entry can be shown to be accurate, and whether their professional opinion was justified on the basis of the evidence that was available at the time the opinion was recorded. If they are not available, you should speak to their manager, professional lead or your Caldicott Guardian.

Where the health and care professional states that the record is correct, amending the record would not normally be allowed. This is because it would affect the authenticity and integrity of the record. If an amendment is not made, then the patient or service user has the right to have an entry put into the record to say they do not agree with particular content and why.

Even where it is agreed that health or care information is inaccurate, you should advise health and care professionals that information must not be deleted without seeking the advice of the information governance team. This is because it will be necessary to consider who has viewed the inaccurate information and possibly relied upon it to make care and treatment decisions. The inaccurate information may therefore need to be retained so that it can be taken into account at a later date to understand a decision about the care received. Instead, you should add a note to the record explaining that the information is inaccurate and should no longer be taken into account.

If the requestor is unhappy with this decision, they may complain to the organisation. If they are still not happy after this, they can complain to the ICO, and also seek redress through the courts. Where your decision is challenged you should ensure that you submit evidence to the ICO, and to the courts if necessary, to justify your decision. You should also be willing to defend the retention of information where it is necessary for the purposes of people’s care, or for professional autonomy.

You should only act upon an order to delete personal information if:

• you are certain that you have made the strongest case for retaining the information; and
• your argument for retaining the information has been rejected by the deciding body

If a request for access to a whole record has been made, such as a Subject Access Request or a court order, the record must not be amended or deleted. It would be a criminal offence under the Data Protection Act 2018 to amend or delete a record once a request for access has been made. However, if a court has requested one part of the record this would not prevent you from amending a different part of the record at a patient or service user’s request. For example, if the court has requested that test results be disclosed this would not prevent you from completing someone’s request to change their address.

Where there is a shared care record, the policy needs to set out who deals with requests to amend records. Where an organisation provides the others in their group with ‘view only’ access, they will be responsible as Controller for making any necessary amendments in their record, subject to organisational policy. Where a shared care record uses a single system for all organisations in their group, then how these are handled must be agreed by all controllers, and also be subject to local policy. As a rule, it is usual for the organisation who the staff member works for to make any amendments in entries made by their staff.

Further information

• Nursing & Midwifery Council: guidance on the Code for professional standards of practice and behaviour for nurses, midwives and nursing associates
• General Medical Council: good medical practice for keeping records
• Health & Care Professions Council: guidance on record keeping
• Medical Defence Union: guidance on effective record keeping
• Digital Social Care: template policies for record keeping