Here's the right way to correct medical records

The Australian Privacy Principles (APPs) (in the Commonwealth Privacy Act 1988) apply when working in the private sector such as in a GP or other specialist practice.  

APP 13 outlines your obligations for correcting information you hold about a patient, in line with your obligation under APP 10 that information is accurate, up to date and complete. These include: 

• correcting any incorrect or misleading information 
• informing other entities that the previous information was incorrect 
• responding in writing if you disagree the information is incorrect (see below for more information) 

 The APPs also require you or your practice to include information in your privacy policy about how patients can request correction of their information. 

For more information see Chapter 13: APP 13 Correction of personal information | OAIC 

There is separate legislation and/or information privacy principles in all states and territories that outlines how records should be corrected in the public system. In Victoria and the ACT, the same legislation applies to public and private health records. In New South Wales, there is separate legislation for managing requests to amend records in the public and private systems. Be aware of and comply with the legislation that applies in your situation.  

Code of Conduct 

Irrespective of where you practise, all medical practitioners have professional obligations outlined in the Medical Board of Australia’s Code of Conduct requiring that you ensure your medical records are accurate and up-to-date, contain relevant clinical details and facilitate continuity of care. 

General principles 

Despite all the different sources of obligation, there are some common principles that should guide your approach, including: 

• medical records must always be up to date, accurate, complete and not misleading 
• a person can request their information be amended - this must be in writing in some jurisdictions, which is good practice in all situations  
• appropriate corrections or additions must be made to ensure the record is accurate, up to date, complete and not misleading 
• information should not be deleted from the record when making the correction 
• anyone who received the incorrect information should be notified – this is optional in some jurisdictions and required in others  
• requests can be declined, with reasons given – for example, if there is a difference of opinion rather than genuinely inaccurate information – and a note about the request should be kept with the records 
• there should not be any fee charged for the process of considering a request or amending the record. 

Can you omit information? 

If the information is clinically relevant, you need to include it. That means sometimes a sensitive diagnosis or history will need to be included. 

If patients are concerned about this, you should be able to reassure them that the record will be confidential and only those with a genuine clinical need will have access to the sensitive information. 

Most software allows you to make a separate ‘confidential’ progress note. This note will then only be visible to the provider who made the entry. If you are not familiar with that function, you can speak to your practice manager or IT manager. 

Incorrect information 

Patients generally have a right to request that you correct personal information. This, along with the requirement to keep records accurate and up-to-date, means you must correct errors in the record. 

How you amend the record depends on the nature of the error, the jurisdiction you’re in and whether the information is in your private practice or in public health records. 

Before making any changes you need to be satisfied the original information is incorrect. You also need to do so in a way that complies with any additional legal obligations that apply in your jurisdiction.  

Demographic information such as an address or phone number can simply be updated. 

For other information, you should generally correct the information – for example, annotate or strike it through – rather than deleting or obscuring the original information (see below for more information). Deletion is prohibited in some jurisdictions (Victoria, ACT, and SA and Tasmania for public health records).  

In NSW, deletion is permitted in the legislation but the regulations associated with the Health Practitioner Regulation National Law state that no information in a medical record should be obscured or omitted.  

In the WA legislation, information can be deleted if the Information Commissioner certifies that deletion can occur (for example, if it would be impractical or prejudicial to retain the information). Given the overarching position in the APPs, we recommend you do not delete incorrect information.   

Updated information 

Sometimes a patient changes something they told you at a previous consultation, such as providing new information about family history that they have since confirmed with relatives. 

Generally, you should not amend the previous entry, as this documents the situation as you understood it at the time the entry was made. Instead, make a new note that the patient has corrected previous information, and also update the summary information in their record to reflect the new information. 

Disputed information 

Sometimes a patient may disagree with something you have documented. 

If they are asking you to change clinical information, it is important to understand whether this represents an error in the original record or a difference of opinion. 

If an error, you may need to make a correction, or you may need to include a record that the patient disputes the previous information. 

Either way, you should generally make a contemporaneous note that the patient has now provided different information or disagrees with the previous information and refer to the date of the earlier entry. 

You should also reflect the change in the summary information and communicate that to other treating practitioners or third parties as needed depending on the clinical context. 

Generally, you should not delete information in the record, given the potential for this to be misleading. This is particularly the case in those jurisdictions where deletion is prohibited. If you have made an entry in error, the entry should be struck through but remain readable, with a signed and dated contemporaneous note explaining the situation. 

However, you may believe that incorrect information could lead to patient harm. For instance, information entered in the wrong patient file could have an impact on the patient’s care, and would also be a privacy breach. 

This is one exception where you might be justified in removing the incorrect information, or you may need to move it to a separate secure section of the patient’s file where access can be restricted so it doesn’t cause harm or confusion. 

You should make notes in both patients’ records explaining what happened, while still protecting the privacy of both patients. 

The safest course is to take all steps to avoid entering information in the wrong file. Speak to your practice manager or IT manager if you find yourself in this situation. 

Under no circumstances should you seek to alter or remove a record for your own benefit; for example, to cover up or justify a clinical error or complication. 

Falsifying records is taken extremely seriously by regulators and may lead to disciplinary action. See a case example here.  

So back to Jenny – in that situation you should sensitively explain that her termination is clinically relevant and therefore needs to be documented in her records. If relevant to your location, you can tell her that legally you cannot delete the information. Reassure Jenny that the information is confidential and that it would only be disclosed to other practitioners involved in her care if clinically relevant. You would need to take appropriate steps to ensure this is not listed on her health summary generally and is not disclosed inappropriately.   

Avant Factsheet: Medical records the essentials  

Avant eLearning course:   

The Office of the Australian Information Commissioner’s Guide to Health Privacy on correction of health information by health service providers. 

For medico-legal advice, please contact us here, or call 1800 128 268, 24/7 in emergencies.