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Making Retrospective Changes to Entries on the GP Medical Record

Updated on 01 December 2015, 704 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.