NIGB issues guide to changing records

The Department of Health is to drop its advice that patients unhappy with their health record must make a formal complaint before a comment can be added to it.

The National information Governance Board said it had disagreed with the DH and the Department had agreed to change its guidance as a result.

The health records watchdog has now published its own advice to patients on how to get amendments made to their health and social care records if they believe they contain an error.

The watchdog’s guidance also has a section for professionals on how to deal with requests to change the content of the records.

Harry Cayton, chair of the NIGB, said the delivery of health and social care was more than ever before a partnership between the professionals providing care and the people receiving it.

He added: “Patients and service users expect their records to be an accurate reflection of their consultations including their own views. Where there is disagreement about a fact, or opinion, recorded in their notes we want people to know how to set about correcting it.”

The guidance makes it clear that audit trails on electronic records must stay complete, but explains that changes can be made to electronic records which mean the clinicians in charge of the patient’s care will not be able to gain access to the audit trail.

The guidance adds: “It is not safe for you, or the professionals providing your care, for information to be completely removed.”

However, the guidance also points out that the Information Commissioner agreed in June last year that Summary Care Records can be deleted if a patient asks for the SCR to be removed and it has not been used for clinical care.

The guidance says this fits with the NIGB’s advice since information is not entered directly into the SCR but comes from other electronic record systems so the audit trail will remain complete.

On ‘secondary uses’ of patient data, the guidance says it should be possible to correct information sent to a national electronic system for secondary uses if the information has been corrected in the system used for directly providing care and if it is possible to identify the patients from the information held on the secondary uses system.

The guidance says that where patients disagree about a record’s content a note should be added to the record. If information is incorrect the information should be corrected and a note added explaining what was corrected, why, by whom and when.

The NIGB tells patients that if they are disputing an opinion “an opinion is not incorrect just because you, or another professional you ask, disagree with it.” In this case the guidance says a note of the patient’s concerns should be added to the record.

The guidance says patients concerned about what is in their health or social care record should first approach the person who made the entry, or the clinician who currently holds the record, the GP practice or chief executive of the hospital which holds the record, or the director of adult or children’s social service at the complainant’s local council.