Errors In Medical Records

We aim to keep your medical records accurate, clear and up to date. If you believe something in your record is incorrect or incomplete, please let us know. We take all concerns seriously.

You can raise this with any member of staff, either verbally or in writing. There is no charge for requesting a correction.

1. Administrative or Filing Errors

If information has been added to the wrong record, coded incorrectly, or filed in error, we will:

• Apologise and investigate promptly

• Correct the error as soon as possible

• Ensure the amendment is clearly recorded

Some errors may need to be reviewed under data protection regulations.

2. Disagreement with a Diagnosis or Clinical Entry

If you disagree with a diagnosis or clinical opinion recorded during a consultation at this practice, you will usually be offered an appointment to discuss this with the clinician involved (or another appropriate clinician if they are unavailable).

After review, we may:

• Amend the record if an error is identified

• Add clarification

• Record your view in the notes if there is a difference of opinion

Clinicians are required to maintain accurate and clinically relevant records. We cannot remove information that reflects a professional opinion made at the time, but your concerns will always be documented.

3. Information from Hospitals or Other Services

If the information you are concerned about was created by another organisation (for example a hospital or specialist service), we are unable to alter their correspondence.

You will need to contact the organisation that produced the document to request a correction. Once they provide updated or amended information, we will update your record accordingly. Where appropriate, we can note that the information is disputed while this is being reviewed.

Complaints

If you are dissatisfied with the outcome of a record review, you may submit a formal complaint in line with the Practice Complaints Policy.

Please note that submitting a complaint is unlikely to speed up the process of reviewing or correcting records, as amendments must still follow appropriate clinical and governance procedures.

Further Information

Our approach to maintaining accurate medical records is guided by national professional and regulatory standards, including:

• General Medical Council
  https://www.gmc-uk.org/professional-standards/the-professional-standards/decision-making-and-consent/recording-decisions

• Nursing and Midwifery Council
  https://www.nmc.org.uk/standards/code/

• Health and Care Professions Council
  https://www.hcpc-uk.org/standards/meeting-our-standards/record-keeping/

• Care Quality Commission
  https://www.cqc.org.uk/guidance-regulation/providers/regulations-service-providers-and-managers/health-social-care-act/regulation-17

• Information Commissioner's Office
  https://ico.org.uk/for-organisations/uk-gdpr-guidance-and-resources/data-protection-principles/a-guide-to-the-data-protection-principles/accuracy/

• NHS England
  https://transform.england.nhs.uk/information-governance/guidance/records-management-code/records-management-code-of-practice/

If you would like help accessing any of this information, please speak to a member of our team.