CLINICAL notes are an important record of the encounters between medical or dental staff and their patients. Their contemporaneous nature means they are relied upon in both a clinical and legal context; hence any attempt to alter them in a less than honest and straightforward way will result in sanction for the practitioner involved.
Notes offer a primary record of all care provided and assist in ensuring continuity and communication. They can be reviewed in any medico-legal process and, in addition, are of fundamental value for audit and planning to help with service provision and improvement.
Data Protection Act breaches attract a lot of attention because of the huge fines that can be imposed; however, inappropriate alteration of records can also result in serious sanctions. There must be a legitimate reason to alter records in any way. Records changed to reflect more positively on the healthcare provider come with a risk of significant sanctions, including a finding of impaired fitness to practice by regulators. At the less serious end of the spectrum, doctors may face an official ‘warning’ if they have altered records inappropriately or failed to adequately identify retrospective entries.
In more serious cases healthcare professionals have faced criminal investigation with subsequent prosecution and imprisonment as result of ensuing fraud cases.
Currently there is much interest in the new General Data Protection Regulation which will come into force on 25 May 2018. The greater ease of access which will be granted next year is likely to lead to many patients seeking to view their records and looking at the accuracy of what is written. Also, the Regulation will keep and reinforce the need for accurate records.
In any medico-legal case the contents of the records will usually be central to the enquiry. In such circumstances it is natural for a practitioner to check what was written in the records. It might be tempting to add to them if on looking back it appears that the record was not sufficiently detailed. However, it is absolutely wrong to amend records in these circumstances. If there is additional information about a case it can be provided in statements or reports but it should never be added to the original record in such a way as to suggest that it had always been there.
Is it ever reasonable to alter or add to medical records?
The short answer is “yes”. The most obvious situation is where an entry has been made in error. Clearly this should be amended. The time of the alteration, a brief description of why and who has made the change should be noted.
If additions are necessary, for example because something has been forgotten, the change must be dated when it is made, stating what it relates to, why it has been added, and again the author should be clear. Retrospective entries must be identified.
Any amendment must be for a legitimate reason that can be explained in the notes, with clear timings and authorship also noted. In modern practice with electronic audit trails, all entries can easily be checked and any audit trail must match the entries in the record.
The GMC offers advice about record keeping in many of its publications, and in Good Medial Practice it states: "Documents you make (including clinical records) 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."
The GMC also advises: "You must be honest and trustworthy when writing reports, and when completing or signing forms, reports, and other documents. You must make sure that any documents you write or sign are not false or misleading."
Similarly, the GDC in its Standards for the Dental Team states: "You must make and keep contemporaneous, complete and accurate patient records."
- Keep up to date with professional guidance about record keeping.
- If you must alter records ensure you have a clearly legitimate reason and can state this when making an amendment.
- Any amendment must be accurately dated and signed, showing that it was made retrospectively.
Dr Gail Gilmartin is a medical and risk adviser at MDDUS
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