Medical Matters > Medical Records

ME Essential Spring 2020

Question

I am currently in dispute with my GP – who is refusing to correct some inaccurate medical information that was written in my medical notes. The GP maintains that this reflects a difference of opinion over what was said at a previous consultation. However, I believe the information about what I am capable of doing, both physically and mentally, is inaccurate and could have an adverse effect when it comes to him providing information to the DWP on my benefit claim for personal independence payment. What can I do to get this corrected?

Answer

Information that is recorded in your medical records should represent an accurate and ongoing account of all key aspects of your clinical care. Medical notes also have an important medico-legal purpose in the event of a complaint or legal claim. So it is in the interests of both doctors and patients to accurately record what took place during a consultation.

This means including all relevant medical information, as well as any concerns, wishes or instructions that are expressed by a patient. However, there are bound to be occasional instances where the record of a consultation or treatment could be upsetting for a patient or where a patient disagrees with their GP’s clinical opinions. So some flexibility has to be made in practice.

The Patient's Association:

Seeing Your Medical Records | March 2022

“Your records include any information about your physical or mental health recorded by a healthcare professional. This includes records made by hospital staff, GPs, dentists, and opticians. It can also include health records kept by your employer. Here are examples of the type of information which could be included:

    • Laboratory reports
    • Recordings of telephone calls
    • X-rays
    • Letters
    • Prescription charts
    • Clinical notes.”

Information from this website also includes: How to get your GP records, requesting the records of someone who has died, seeing a child's medical records, requesting the records of a vulnerable adult, useful links for England, Wales, Northern Ireland, and, Scotland, and access to a free telephone helpline.

The introduction of the General Data Protection Regulation (GDPR) in 2018 means that GP practices now have clear legal obligations in these situations. And while the basic principles of GDPR are similar to those set out in the Data Protection Act 1998, the new legislation requires much greater transparency from those who hold personal data and makes the rights of data subjects much more explicit, including the right to correct inaccuracies (Article 16 of the GDPR).

Doctors need to respond appropriately and without undue delay when patients (or their representatives) want to exercise these legal rights. A Template Letter has been prepared by the ICO along with tips on how to make your request more effective.

The Information Commissioner’s Office (ICO) in a Guide to the GDPR makes the following points:

  • Requests for rectification can be made verbally or in writing.
  • Requests can be made to any part of an organisation rather than a specific person.
  • A request should be considered valid as long as the individual has challenged the accuracy of their data and has asked for it to be corrected. There is no need for individuals to reference the GDPR.
  • It is good practice for organisations to have a policy for recording details of requests and to check that staff have understood them. The ICO recommends keeping a log of verbal requests.
  • Organisations cannot charge a fee to comply with a request for rectification unless the request is manifestly unfounded or excessive when it is possible to charge a ‘reasonable fee’ for the administrative costs. However, they must be able to justify the decision. There is no definition of what constitutes a manifestly unfounded or excessive request or a reasonable fee.
  • Organisations must act upon the request without undue delay and at the latest within one calendar month of receipt. This may be extended by a further two months when the request is complex but the organisation must keep the requestor informed. If you aren’t able to reach a solution to this problem I suggest you make use of the information I have provided and write to the Practice Manager at the surgery – copying in the Senior Partner.

More information

MEDICAL DISCLAIMER

Medical Matters is for information purposes only. The answers provided by Dr Shepherd and the ME Association’s other expert advisers should not be construed as medical advice. We recommend that any information you deem relevant is discussed with your GP as soon as possible. It is important to obtain advice from a GP who is in charge of your clinical care, who knows you well, and who can consider other likely causes for symptoms. Seek personalised medical advice whenever a new symptom arises, or an existing symptom worsens. Don't assume that new or worsened symptoms are a result of having ME/CFS.

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