GOOD clinical record keeping is a crucial part of medical and dental practice, and there is a wealth of professional guidance covering all aspects of how to get it right.
One key risk area that MDDUS advisers are often asked about is altering clinical records – when is it allowed and how exactly should it be done?
A late addition
Professional guidance for both doctors and dentists advises that clinical notes should be contemporaneous – meaning they should be written at the time the treatment is given, or as soon as possible afterwards. The General Medical Council’s Good medical practice guidance states (at par 19) that: “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 General Dental Council’s Standards for the dental team advises (principle 4.1) that dentists “must make and keep complete and accurate patient records… each time that you treat patients.”
While clinicians should always try to make notes as close as possible to the time of treatment, there are circumstances where this is more challenging, such as attending to a patient out of hours (at home or in hospital), working remotely or because of technical difficulties.
Where it is not possible to make a full contemporaneous note, this should be added at the earliest opportunity, with a clear note alongside explaining when the consultation took place, when the note was made and the reason for delay.
There are occasions when it will be reasonable for a doctor or dentist to want to alter an existing record. For example:
- a factual error/inaccuracy is discovered
- non-standard abbreviations were used, suggesting further clarification is required
- shorthand has been used which provides little substantive information for other health professionals (for example, in relation to valid consent – ‘risks discussed’)
- certain pieces of subjective information/comments have been recorded which are later found to have no clinical relevance.
Making changes clear
Clinicians must have a legitimate reason to alter a patient's record. Any changes must be clearly marked, showing the name of the person making the change and the date the change was made.
The GDC makes this clear in principle 4.1.5 of its Standards guidance, which states: "If you need to make any amendments to a patient's records you must make sure that the changes are clearly marked up and dated".
Record entries should never be deleted or obliterated. Instead, when making hand written entries in medical records, draw a line through the original entry (ensuring it remains legible) and add a clear updated note alongside, including the date the new entry was made and the name and grade of the person who has made the changes. Never use white-out fluid.
When making changes to electronic records, the principle of transparency is paramount so that the record clearly shows when and by whom an entry was changed. Some examples are detailed under the 'common scenarios' below.
Remember that electronic record systems include a clear audit trail of changes made. Any alterations found to have been made without an accompanying explanatory note, such as the insertion of new notes or deletion of an initial diagnosis, will be viewed seriously by the regulators and could lead to accusations of dishonesty.
Consider these common situations that clinicians may encounter:
- Additional information has come to light since the original entry was made, or information was accidentally missed from a previous encounter. The clinician can make an additional entry, clearly stating and clarifying the position. Such entries should be dated at the time of entry and not retrospectively inserted into a record.
- Something is discovered to be factually incorrect. It can be removed but with a separate entry and explanation recorded as to why (including if the patient has asked for it to be deleted with reference to the Data Protection Act). A specific administrative code can also be used to explain why an existing code is being deleted from the patient record if applicable.
- A clinician and a patient disagree about the accuracy of a record. Entries should not be deleted that a clinician believes to be factually correct. A note explaining the patient’s views can be included in or appended to the record. This will allow other clinicians accessing the record in the future to be wary of placing undue weight on disputed information.
- Patient citing 'right to be forgotten'. The data protection principle of 'right of erasure' (sometimes referred to as the 'right to be forgotten') is not absolute and only applies in certain circumstances. At MDDUS we often receive enquiries from members concerning patients who for various reasons wish certain information removed from their medical history under this principle. The 'right to erasure' does not apply to personal health information, which is classified as ‘special category data’, where processing is necessary for the purposes of preventative or occupational medicine.
- Entry accidentally made in the wrong patient record. This must be removed and reconciled with the correct patient record, but again with an appended note made explaining the removal. Data protection laws require that personal information being processed must be accurate and a failure to correct this could be classed as a data protection breach.
- Patient claims that a particular event or piece of information is missing from their record and the clinician has no independent means of validating this. A note to that effect can be added to the record explaining the position.
- Clinical records should, wherever possible, be made contemporaneously.
- Never alter patient records without a legal basis or other justifiable cause.
- Where records require to be amended or updated, be clear about the reasons for this and transparent about where and when it was done.
- NHS England has more detailed advice on amending patient records.
- Read MDDUS guidance on record keeping for GPs and GDPs (member login may be required).
This page was correct at the time of publication. 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.