Medical records - England factsheets - MPS UK
Additions or alterations
If you need to add something to a medical record or make a correction, make sure you enter the date of the amendment and include your name, so no one can accuse you of trying to pass off the amended entry as contemporaneous. Do not obliterate an entry that you wish to correct – run a single line through it so it can still be read.
Patients have the right, under the Data Protection Act (DPA), to ask for factual inaccuracies in the record to be rectified or deleted. The Act does not, however, give them the right to ask for entries expressing professional opinions to be changed. You should only comply with a request if you are satisfied that it is valid – ie, the entry is indeed factually inaccurate, but if you decide that a correction is not warranted, you should still annotate the disputed entry with the patient’s view.
If you decide that the request is valid, add a signed and dated supplementary note to correct the inaccuracy and make it clear that the correction is being made at the patient’s request. Avoid deleting the original entry, though. If the patient demands nothing less than deletion, then this should be done in exceptional cases – and only then in paper records, never electronic. This must be discussed fully with the patient.