Amendments to Healthcare Records
Should the patient feel that there is inaccurate information held within the notes, they have a
right to ask for it to be amended. Incorrect demographic information will be immediately
corrected. If the information is clinical then it will have to be investigated by the Trust before
an amendment can be made. The investigation will end in one of the following outcomes:
• The Trust rules that the information is correct and it will not be amended. The patient
can appeal to the Information Commissioner for an independent investigation if this
happens. The Trust will also agree to a statement from the patient being placed in the
notes, which explains their disagreement with the information held therein.
• The Trust agrees what the information is incorrect. However, it is illegal to modify the
documentation as it represents “historical information” which could have influenced
subsequent events. Therefore a note will be placed in the file which alerts the reader
to the inaccuracy and the correct facts. The patient and the Trust will agree the
contents of the note.