AQW 5896/22-27


Ms Claire Sugden
Independent
East Londonderry


Tabled Date: 08/02/2024
Answered On Date: 15/02/2024
Priority Written: No


Question:
To ask the Minister of Health to detail (i) the process by which a person may change their medical history records; (ii) plans he has to improve this process; and (iii) the conditions or evidence required for this process to go ahead.


Answer:
Health and Social Care (HSC) organisations should make every effort to keep patient records accurate. However, occasionally information may need to be amended about the patient or their care.
If a patient feels that the health or care information in their record is factually inaccurate Article 5 of UK General Data Protection Regulation (GDPR) legislation provides a legal right to rectification. For example, a patient can ask for their home address to be changed because they moved house. They may also ask for something they feel has been inaccurately recorded, such as a diagnosis, to be corrected. However, it may not be possible to agree to all requests.
A request can be made either by speaking to staff in the relevant HSC organisation (for example Health and Social Care Trust or GP Practice) or by making a request in writing. The patient may need to provide evidence of the correct details, for example proof of address or change of surname after marriage. The organisation will then consider the request. Where organisations agree to make a change, they should make it as soon as practically possible and within one calendar month. In certain circumstances, if the rectification is deemed complex, timescales could be extended to a maximum of three months for this rectification to happen.
On occasion, a patient may disagree with information written in their record, but the information could still be factually correct. For example, the patient may disagree with a diagnosis they were given in the past. Whilst they can still ask the organisation to amend the entry that they feel is inaccurate, an organisation will consider with the care professional whether they believe it is factually correct. There may also be times when information was correct at the time the entry was made but has since changed. For example, there may be an initial working diagnosis which was, at the time of entry, clinically possible, but is later ruled out with a different confirmed diagnosis. Retaining the original diagnosis does not make the record inaccurate, so it is important that this is not amended. There are exceptions to this, for example, where there is a court order requiring an amendment.
In cases where all parties agree that the information is inaccurate, it may still be necessary to retain the information. For example, health and care professionals may have taken the information into consideration when making decisions about treatment or care. This information would therefore be needed to justify and explain health and treatment decisions or to audit the quality of care received. The patient can, however, request for a comment or entry to be made in the record to show that they disagree with the content and what they think it should say.
If the patient is unhappy with the decision of a health or care organisation to retain information they wish to have deleted or rectified there are steps a patient can take. In the first instance, the patient can make a formal complaint through the organisation’s complaints process. If a patient is unhappy with the outcome of that process then they might consider making a complaint to the Information Commissioner’s Office (ICO) or they may consider legal action.
There are well established processes in place across the HSC to deal with requests for changes to medical records which are supported by legislation; there are no plans to amend those processes at present.
Health and Social Care Professionals have a legal duty and professional responsibility to keep health and care records accurate and up to date. Patients and service users have the right under UK GDPR to request for their records to be rectified if they feel inaccurate information is held about them. There is an expectation on organisations to confirm whether they will rectify the information, or if they are unable to do so explain this to the individual. Whilst it is difficult to challenge the accuracy on subjective opinions, this should be explained to the individual.
Where a factual inaccuracy exists the HSC organisation may request evidence to support a change to the medical record. This could, for example, be proof of a new address, a copy of a marriage certificate to support a change of surname, a copy of a birth certificate to correct Date of Birth.
Where the inaccuracy relates to subjective opinion it becomes more difficult to establish evidence to prove/disprove accuracy and therefore the need for rectification. In such circumstances the patient should engage with the relevant organisation.