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Here's the right way to correct medical records

17 October 2019 | Ruanne Brell, BA, LLB (Hons), Senior Solicitor, Medico-legal Advisory Service and Emma Gibson, RN, ICU Cert, Cert IV workplace learning and development, MHM, Risk Adviser, Avant

In recording the complexities of a patient’s life, mistakes happen.

Patients may ask for sensitive information not to be included in their record, or they may ask you to amend or delete a previous entry.

What are your obligations?

Can you omit information?

If the information is clinically relevant, you need to include it. As outlined in the Medical Board of Australia’s Code of Conduct, doctors are required to ensure their medical records are complete, accurate and up-to-date.

That means sometimes a sensitive diagnosis or history will need to be included.

If patients are concerned about this, you should be able to provide them with some reassurance that the record will be confidential.

Most software allows you to make a separate ‘confidential’ record and include details in the notes that the patient disclosed sensitive health information but asked you not to record this.

If you are not familiar with that function, it might be helpful to speak to your practice manager or IT manager.

Amending the record

Patients generally have a right to request that you correct personal information. This, along with the requirement to keep records accurate and up-to-date, means you must correct errors in the record.

However, before making any changes you need to be satisfied the information is incorrect. Further, there are specific requirements in some states as to what and how information should be corrected.

Some states stipulate that health records must be corrected in such a way as not to delete any information already contained.

Others have provisions about how to address any potential for harm where incorrect information cannot be deleted from the patient’s file.

So how you amend the record depends on the nature of the error, and you may need to seek specific advice.

For example, demographic information such as an address or phone number can simply be updated.

Sometimes a patient corrects something they told you at a previous consultation, such as new information about family history that they have since confirmed with relatives.

Generally, you should not change the previous record, which documents the situation as you understood it at the time the record was made. Instead, make a new note that the patient has corrected previous information, and also update the summary information in their record to reflect the new information.

Sometimes a patient may dispute something you have recorded.

If they are asking you to change clinical information, it is important to understand whether this new information represents an error in the original record or a difference of opinion.

You may need to make a correction, or you may need to include a record that the patient disagrees with your version.

Either way, you should generally make a contemporaneous note that the patient has now provided different information or expressed disagreement and refer to the date of the earlier record.

You should also reflect the change in the summary information and communicate that to other treating practitioners or third parties as needed.

Deleting information

Generally, you should not delete information in the record, so if you have made an entry in error, the entry should be struck through but remain readable, with a signed and dated contemporaneous note explaining the action.

You may believe that incorrect information could lead to patient harm; for example, where information was entered in the wrong patient file, which could lead to a privacy breach.

This is one exception where you might be justified in removing the incorrect information, or you may need to move it to a separate secure section of the patient file.

You should always make notes in both patients’ records explaining what happened, while still protecting the privacy of both patients.

The safest course is to take all steps to avoid entering information in the wrong file. But speak to your practice manager or IT manager if you find yourself in this situation.

If you have made a clinical error

Under no circumstances should you seek to alter or remove a record for your own benefit; for example, to cover up or justify a clinical error or complication.

Falsifying records is taken extremely seriously by regulators and may lead to disciplinary action.

More information

If you are faced with a complex request or dilemma relating to correcting or amending records, contact us for advice at nca@avant.org.au or on 1800 128 268, 24/7 in emergencies.

Listen to our podcast: making changes to a medical record or read our article, On the record: the importance of keeping good medical notes.

Download The Office of the Australian Information Commissioner’s Guide to Health Privacy on correction of health information by health service providers.

This article was originally published in AusDoc.PLUS on 14 May 2019.

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