What to do when a patient disagrees with their medical records.

Situation

 I am a GP, and a patient has expressed concern about a recent entry in their medical records. The entry describes their alcohol intake as “excessive.” The patient strongly disagreed with this wording, felt it was judgmental, and asked that I delete the entry entirely from their record.  

On review, the entry was made after the patient disclosed during a consultation that they are consuming more than triple the recommended units for weekly consumption of alcohol. The patient explained that they have cut this back and managed to stay within the recommended units in recent weeks. 

They cite GDPR and their right to accuracy of their records and claimed this entry could cause them issues with their occupation if an employer ever requested the patient's medical history.  

I’m sympathetic to the patient’s concerns but I'm also aware I must uphold professional integrity by not altering or deleting factual clinical information. 

Regulatory advice

Under General Medical Council (GMC) good medical practice guidance, doctors must: 

“Keep clear, accurate, and legible records that report the relevant clinical findings, the decisions made, the actions agreed, and who is making the decisions.”  

MDDUS advice

We advise not to delete the records as they are clinical factual entries made at the time of assessment. Reference to the DPA and NHS guidance states that:  

• Patients can request amendments to their records if they believe information is inaccurate. However, there is no absolute right to erasure with medical records.
• If the healthcare professional believes the information is correct, it should not be deleted.
• However, the patient can request that a note or annotation be added to the record to reflect their disagreement. 

We would suggest explaining to the patient and demonstrating empathy that while they are upset at the wording used in their records, it remains clinically accurate at the time the record was made.  

Record the patient’s concerns and their recent improvement in their alcohol intake. Also note the request to delete the entry and the reasons for declining this request. Finally, add the patient’s statement of disagreement to the record.