Do patients have the right to request amendments to their health records but an organization has the right to either accept or deny the proposed change?
There is growing public awareness about the rights of patients to access their records and to request amendments to information which may be inaccurate or incomplete. The MDU regularly receives queries from GP members about whether a record should be amended at a patient’s request. Practices need to know their legal obligations in these situations. Show
Awareness has increased since the enactment of the General Data Protection Regulation (GDPR) in 2018. More recently, government plans to share health records under the General Practice Data for Planning and Research project (GPDPR) may lead to more patients requesting access to their records and querying the contents. Patient records support clinical decision-making and continuity of care, as well as having an important medico-legal purpose in the event of a complaint or claim. It is in the interests of GPs and patients to accurately document what took place during a consultation, including all relevant information, from history and differential diagnosis, to the patient's concerns and expressed wishes. However, there will inevitably be instances where the record of a consultation or episode of treatment could be upsetting for a patient or where they disagree with a GP’s clinical opinions. Managing requests for rectificationPatients have a right to correct inaccuracies in their records under Article 16 of the UK GDPR. It’s important to take reasonable steps to ensure the data in question is accurate and rectify it if necessary. The reasonable steps will depend on the circumstances but should include the arguments and evidence provided by the patient who is the data subject, or their representative The Information Commissioner’s Office (ICO) addresses this in its Guide to the GDPR1 which is summarised below:
Amending medical recordsPatients should be able to report factual inaccuracies or question the content of the records, but they do not have the right to alter their contents because they are upsetting or they disagree with them. In its FAQs for small healthcare organisations,2 the ICO notes that the right of rectification does not mean that doctors are required to remove their clinical opinions. It says: ‘An initial diagnosis (or informed opinion) may prove to be incorrect after more extensive examination or further tests. Individuals may want the initial diagnosis to be deleted on the grounds that it was, or proved to be, inaccurate. However, if the patient’s records accurately reflect the doctor’s diagnosis at the time, the records are not inaccurate, because they accurately reflect a particular doctor’s opinion at a particular time. Moreover, the record of the doctor’s initial diagnosis may help those treating the patient later.’ You should restrict processing personal data while you are verifying the record’s accuracy whether or not the patient has exercised his/her right to restrict processing. You cannot alter a record that is an accurate representation of the situation at the time the note was written, however you can make an additional note to record that the patient disagrees with the opinion. See the case examples below. If a factual correction is necessary, such as a misspelt name or incorrect date of birth, it must be obvious who made the amendment and when (computerised records usually create an audit trail). Refusing requestsIf you refuse a request for rectification, you must explain why to the patient and tell them of their right to complain to the practice and/or the ICO. The ICO also recommends keeping a note, indicating that the patient challenges the accuracy of the information in the records and their reasons for doing so. Ultimately, a patient's record should be complete and accurate to ensure they receive appropriate care. If you have disclosed the personal data to others, such as secondary care, you should contact the recipients, if possible, to inform them of any amendments to the data. Case examplesThe following anonymised examples, which are based on MDU cases, are typical of the types of requests made to amend records. Patient objects to working diagnosis At a later consultation the patient was unhappy to learn that the initial consultation entry included a potential diagnosis of sexually transmitted diseases (STD). The patient requested this information be removed from the record. The GP explained this was her working diagnosis which needed to be documented and ruled out. The MDU advised that if information recorded was factually accurate and clinically relevant, then it should stay in the records. This is in line with the ICO’s advice and GMC guidance that clinical records should include relevant findings, decisions made and actions agreed, information given to patients and any investigations or treatment carried out (Good medical practice, paragraph 21). This is important for the patient’s ongoing care. Given the patient’s concerns, the GP suggested an addendum could be added to the records. For example, stating the patient confirmed she was not suffering from a STD and did not think this diagnosis was likely. Rudeness documented The patient asked that this was removed because it was untrue as they clearly recalled the consultation. The note was made by a GP at the patient’s previous practice. The MDU adviser explained it is not advisable to omit that part of the record because the patient doesn’t agree with it. However, the patient could approach the previous practice to raise their dissatisfaction with the GP concerned, if they are contactable. Alternatively, the new practice could add an addendum to the records with the patient’s account of events. This example highlights the issue of subjective terms being used to describe patient behaviour. Unless the behaviour is clinically relevant, it is advisable not to document it in the medical record, so that it does not prejudice future care. This is the same principle under which complaint correspondence and statements about adverse incidents, unless relevant to ongoing provision of clinical care, are placed in a separate practice folder. A letter in the wrong records The practice apologised for the error and removed the page from the records as it was not clinically relevant to the patient’s care. They were able to identify the correct patient after making contact with the psychiatrist who had signed the letter so the information could be correctly filed.
References
Can individuals request to have an amendment made to their medical records?Under HIPAA, patients have a right to request amendments to their medical records, but it is up to the provider to decide whether or not to do it. However, regardless of what the provider decides, they must respond to the patient's amendment request.
Who has the right to request an amendment?The Constitution provides that an amendment may be proposed either by the Congress with a two-thirds majority vote in both the House of Representatives and the Senate or by a constitutional convention called for by two-thirds of the State legislatures.
How are amendments handled in the EHR?How are amendments are handled in the EHR? The amendment must have a separate signature, date, and time. Data Validation includes an undo button. policies should address how the patient information will be removed from computers at the end of their useful life.
What is a patient required to do for a request to restrict the use or disclosure?The request must be made in writing. Emergency Treatment exception: If the facility agrees to a restriction request or a portion thereof, HIPAA privacy regulations provide an exception in emergency treatment situations for a hospital or provider to use and disclose necessary information to treat the patient.
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