Menu Home Search

Making Retrospective Changes to Entries on the GP Medical Record

Updated on Tuesday, 1 December 2015, 1173 views

As a rule entries in the medical record should not be changed once written.  All changes can be picked up in an audit trail if ever the electronic record is examined   forensically, so if for any reason a record is altered, the reason for this should be permanently recorded.

There will be occasions when a record needs to be changed:  for example, if entries have been made in the wrong patient’s notes, these should be deleted and replaced with a suitable deletion code and a free text entry, something like “Note deleted: data for another patient was entered in error”

From time to time a diagnosis or other entry that was appropriate when it was made needs to be amended or changed in the light of later information. Again, the reason for correction or deletion should be clear in the notes.  We suggest that if you overwrite a diagnosis code you should add in free text    “previously coded incorrectly as xxxxxxxxxxxx”.

A more tricky problem may arise if a patient wants to have his or her record changed or notes added or deleted.  A good starting position is to offer to add the patient’s comments in free text with an appropriate date.  So, if the diagnosis code is  “ Asthma”  and dated 11.05.06 and the  patient is wanting to dispute this because she is  seeking to join the army , you  could add in free text  “ patient reviewed notes on 12.11.15 and states he has never had asthma”.  Obviously prescription issues for salbutamol and the asthma review codes would not be altered.

Occasionally   a GP will make a note in the record about a conversation with a patient that the patient later disputes.  If the record is written from the GP’s perspective “I felt the patient was being aggressive” then it should not normally be changed, though the patient comments should be added in free text.  But if the note was written from the patient’s perspective “Patient felt I was being aggressive” it should be changed the patient if says that this was not what he or she actually felt, unless there is clear evidence to the contrary.

Related guidance...

Somerset Weekly Update Friday 1st September 2017

All Somerset GPs and Practice Managers This and previous updates can be found here The Birds and Bees- Latest Blog from LMC Chairman...

Top Tips

Top Tips 2020 28.8.20 Cytology Things to consider: Age Group - Patients aged 25 - 49 are eligible for screening every 42...

Safeguarding: Filing of Child Protection Documents

The LMC has decided to issue a more detailed position on this area. The GMC states the following: “You should store information or...

Safeguarding: Filing of Child Protection Documents

The LMC has decided to issue a more detailed position on this area. The GMC states the following: “You should store information or...

Somerset LMC Weekly Update Friday 29th January 2016

Sent to all Somerset GPs and Practice Managers This and Previous updates can be found here Are you worried that...

Retention of Medical Records

It is not possible to be absolutely prescriptive on these matters but the following information should give some basic...

Transgender Patients/Gender Reassignment

A patient may request to be known by a different gender with or without the legal recognition which will only follow after the issue of...

All Somerset GP's & Practice Managers

Sent to all Somerset GPs and Practice Managers This and previous updates are available here SGPET Covid weekly update with all...

What are the rules on treating overseas patients (Including Refugees and Asylum Seekers)

Do I have to treat a patient who lives overseas or is not a British citizen? Yes - anyone in England, regardless of nationality and...

Somerset LMC Weekly Update Friday 14th December 2018

Sent to all Somerset GPs, Practice Managers and Lead Nurses This and previous updates are available here A Tale of Two...