Section 3Medical Records
Demanding a change to the records MDU advice
A GP member saw a newly registered patient. The MDU adviser confirmed that the GP was correct in
During the consultation the GP referred to the thinking she should not change or delete any information
patient’s HIV positive status, which was documented recorded in the records unless it was factually inaccurate.
in his recently transferred medical records. The The Data Protection Act 1998 gives patients the right to
patient was horrified and said that although he request that details that are factually incorrect, such as a
was HIV positive, he was not aware that it appeared wrong name or date of birth, be altered, but not
in his records. He requested that the information relevant medical information that they simply do not
be deleted. He confirmed that the condition was want to appear. The GP was advised that she could
stable and that he was seeing a hospital consultant document the patient’s preferences and views on the
on a regular basis. matter in the records, but she should not delete or alter
The GP reassured the patient about her duty of
anything that was not factually incorrect. The GP was
confidentiality and that this also applied to all practice
also reminded of the GMC’s guidance in Good Medical
staff. But she went on to explain that she could not
Practice(2006) that states: ‘In providing care you must
delete an entry that formed part of a patient’s electronic
keep clear, accurate and legible records, reporting the
record. However the patient was insistent not only that
relevant clinical findings, the decisions made, the
the electronic records be altered but that any reference
information given to patients, and any drugs prescribed
to his HIV status be blacked out from the paper records.
or other investigation or treatment.’
The GP, an MDU member, contacted the MDU for advice. The GP was advised to have another consultation with
the patient to inform him that the records could not be
altered but that the patient could add a note of his
concerns to the records. The GP might also wish to
reassure the patient that doctors should acquire patient
consent before disclosing records to another member of
the healthcare team or to others providing care, as stated
in Paragraph 10 of the GMC guidance ‘Confidentiality:
Protecting and Providing Information’(2004).
The patient returned to the surgery the following week
and the GP repeated her reassurance about the duty of
confidentiality that all practice staff owed to patients.
The GP also explained why it might be relevant to the
patient’s care for healthcare professionals to know about
his HIV status. But the patient was unconvinced. He said
that he had never given consent for the information to
be recorded in the records and it should be deleted.
The GP repeated to the patient that she was unable to
alter the records or delete them but could insert his views
on the matter within the notes. The patient was unhappy
with this and stated he would be taking further advice.
The patient presented again to the GP two weeks later.
He had thought about the discussion that had taken
place and accepted that the doctor was unable to change
the records that had already been made. He did however
want a repeat reassurance that his HIV status would be
kept confidential and not necessarily disclosed to any
other members of the practice healthcare team or indeed
any other healthcare workers in the event that a referral
was made to another doctor, without first seeking his
consent. The GP assured him that this was her usual
practice. He also requested that documentation of the
concerns he had raised be made within his records, which
“…the doctor was unable to
was agreed to by the GP.
change the records that had
already been made.”
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