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Medical Records Are Not Personal Health Records: Managing Increasing Requests to Rewrite Clinical Records
- 20 hours ago
- 3 min read
We have noticed a big increase in requests to amend, remove or add information to clinical records since the expansion of patient access to online medical records, and while some requests relate to genuine inaccuracies and should be corrected, others are not appropriate and can be tricky to manage for customers.
Practices report patients asking for large sections of narrative to be added to records, historical consultations to be rewritten or clinical opinions to be removed, and sometimes even assessments to be replaced with alternative interpretations of events.
For us, this raises an important question around where the Right to Rectification ends and the obligations around accuracy begins.
The Right to Rectification Is Not a Right to Rewrite History
Article 16 UK GDPR provides individuals with the right to have inaccurate personal data corrected but the ICO has consistently distinguished between:
Factually inaccurate information.
Professional opinions and clinical judgements.
This means that a patient may disagree with a diagnosis, assessment, interpretation of symptoms, or a clinician's understanding of events, but that disagreement alone does not make the record inaccurate.
The purpose of rectification is to correct inaccurate data, not to retrospectively rewrite an accurate clinical history.
Medical Records Are Clinical Documents
Medical records are not personal health diaries or even a personal health record.
They are professional clinical tools, maintained to support safe and effective care.
Our customers rely on these records to understand previous presentations, risks, investigations, diagnoses and treatment decisions; making the integrity of the record critical.
If every disagreement resulted in historical entries being rewritten, the record would cease to function as a reliable account of clinical care.
What Should Practices Do?
Where a patient disputes a clinical opinion or interpretation:
Review the concern carefully.
Consider whether any factual inaccuracies exist (checking if there is more than one entry of this type, on different dates, for example)
Correct demonstrably inaccurate facts.
Update coding to "past problem" where clinically appropriate.
Record the patient's disagreement where appropriate.
Preserve the original clinical entry unless there is evidence that it is inaccurate.
In many cases, adding a note that the patient disputes an entry is a more appropriate response than altering the original record.
Managing Persistent Requests
Another pattern we see is that practices are sometimes then receiving repeated correspondence from patients seeking further amendments after a request has already been reviewed.
Once a request has been properly considered and a reasoned response provided, practices are not obliged to continually revisit the same issues in the absence of new evidence.
A clear written response explaining the outcome, the rationale, and the escalation routes available can often help bring the matter to a close.
Conclusion
We recognise that patient access to records is a really important part of transparency and patient empowerment, but transparency does not change the purpose of the clinical record.
The medical record exists to support patient care, not to serve as a collaboratively edited account of events. Our customers should be willing to correct inaccuracies, but equally confident in maintaining the integrity of records where no evidence of inaccuracy exists.
💡 Need some templates to help you respond to a request? Customers can find this on the myKafico platform!
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