Information should never be completely removed from an electronic patient record, according to new draft guidance.
The National Information Governance Board for Health and Social Care has drawn up guidance on amending medical and social care records and launched a 12 week public consultation on its recommendations.
The guidance looks at what should happen when someone receiving medical or social care believes there is something wrong with their records and wants them changed or part of the record deleted.
Harry Cayton, chair of the NIGB, said the guidance was intended to address the small number of cases where there was a serious dispute about what was included in a patient record.
He told EHI Primary Care: “It was slightly surprising to us that there wasn’t any guidance for clinicians and patients to negotiate about possible disagreements over what was in a clinical record.”
Cayton said the guidance was intended to achieve clarity for clinicians and patients. He said that while an electronic record may contain an error that could have been relied on in good faith and therefore it would be wrong to delete it.
“Our recommendation is that errors should be suppressed so they can’t be seen but not deleted,” he said.
On paper records, the guidance says removing one or more entries could be compared to taking a chapter out of a book resulting in the following chapter not making sense.
The guidance also seeks to set our where and how patients can add a comment in a record if the disagreement refers to a matter of opinion.
The consultation will run for 12 weeks from today, 11 June, and the guidance was due to be published on the NIGB website – www.nigb.nhs.uk – at midnight.
Cayton added: “We have involved a lot of people in writing the draft but we felt this was important enough and useful enough to have a wider circulation before we finalise it.”