Patients requesting changes to their clinical notes

With more patients having easy access to their clinical records online, some practices are receiving an increasing number of requests from patients who are wanting entries in their record changed.

Patients have a ‘right to rectification’ under GDPR, but this is a right to change factually incorrect statements within their medical records, not just things that the patient feels uncomfortable to read. Examples of things that would be changed are addresses, or which leg has been operated on. Clinically factual words such as ‘obese’ should not be changed.

If a patient has an issue with something that a medical professional has included in their record, but the clinician states the record is factually correct, an entry can be made alongside the clinicians notes to say that the patient disagrees with this and why, but it should not be marked in error on the records.

For more detail on this subject, please see this guide to amending records for patients, healthcare workers and IG professionals.