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Clinical Record Accuracy

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Dear General Medical Council,

1. What standards do doctors have to follow to ensure medical records are accurate?

2. Are medical records considered to be a doctors opinion in its entirety or does the GMC accept that medical records are combination of fact an clinical opinion?

3.The ICO(Information Commisioners Office) says "It is complex if the data in question records an opinion. Opinions are, by nature, subjective. As long as the record is clear that the data is an opinion and, where appropriate, whose opinion it is, it can be difficult to maintain it is inaccurate and needs to be corrected."
Does the GMC expect doctors to clearly show the difference between facts and clinical opinions in patient notes?

4.If a doctor makes comments about a patients ethnicity, or religion, and a patient points out that that is not their ethnicity. Is a doctor allowed to refuse to amend the entry on the basis that it is their "clinical opinion" and therefore correct.

Yours faithfully,

S.Jones

FOI, General Medical Council

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FOI, General Medical Council

Dear S Jones,

 

Your information request - IR1-2534125320

Thank you for your email dated 5 December, in which you ask for the below:

 

1. What standards do doctors have to follow to ensure medical records are
accurate?

 

2. Are medical records considered to be a doctors opinion in its entirety
or does the GMC accept that medical records are combination of fact an
clinical opinion?

 

3.The ICO (Information Commissioners Office) says "It is complex if the
data in question records an opinion. Opinions are, by nature, subjective.
As long as the record is clear that the data is an opinion and, where
appropriate, whose opinion it is, it can be difficult to maintain it is
inaccurate and needs to be corrected."

Does the GMC expect doctors to clearly show the difference between facts
and clinical opinions in patient notes?

 

4.If a doctor makes comments about a patients ethnicity, or religion, and
a patient points out that that is not their ethnicity. Is a doctor allowed
to refuse to amend the entry on the basis that it is their "clinical
opinion" and therefore correct.

 

I’m sorry for the delay in acknowledging your request, this is due to a
significant amount of requests being received.

 

How we will consider your request

We’re going to consider your request under the Freedom of Information Act
2000 (FOIA). The FOIA gives us 20 working days to respond, but we’ll come
back to you as soon as we can.

 

Who to contact

Lucy Myatt will be handling your request. If you have any questions you
can call her on 0161 240 8276 or email her at [1][email address].

 

Yours sincerely

 

Lauren Barrowcliffe
Information Access Team Assistant

 

[2][email address]

0161 240 8356

General Medical Council

3 Hardman Street

Manchester

M3 3AW

 

 

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Lucy Myatt (0161 240 8276), General Medical Council

Dear S Jones,

Your information request - IR1-2534125320.

Thank you for your email dated 5 December 2019, in which you asked about standards regarding clinical record accuracy. I've considered your request under the Freedom of Information Act 2000 (FOIA).

I thought it might help to start by clarifying that we don’t provide in depth guidance on the completion of medical records. However, we do note in Good Medical Practice:

19 Documents you make (including clinical records) to formally record your work must be clear, accurate and legible. You should make records at the same time as the events you are recording or as soon as possible afterwards.

20 You must keep records that contain personal information about patients, colleagues or others securely, and in line with any data protection law requirements.

21 Clinical records should include:
a. relevant clinical findings
b. the decisions made and actions agreed, and who is making the decisions and agreeing the actions
c. the information given to patients
d. any drugs prescribed or other investigation or treatment
e. who is making the record and when.

Whilst the above outlines the general expectations we have in terms of accurate recording, we also expect doctors to use their own professional judgment when inputting and reading this information. In other guidance we do recognise that there can be a difference between clinical findings and opinion (for example, doctors who give evidence in court may need to make clear what is factual evidence and what is opinion based on their professional knowledge and experience) but we do not require this distinction to be made in medical records generally.

With regards to your final query relating to amending a potentially incorrect record, this is beyond our remit to answer, however the ICO provide further guidance on this issue. From a doctor/patient perspective, we say in Good Medical Practice that doctors should work in partnership with their patients and ‘Listen to, and respond to, their concerns and preferences’. Whilst we cannot offer advice on this specific situation, we encourage a collaborative relationship between doctors and patients with regards to all aspects of their care.

Who to contact

I hope you find this information useful. If you have any queries about this or need anything further, please contact me on the details below.

Yours sincerely,

Lucy Myatt
Information Policy Officer
General Medical Council
3 Hardman Street
Manchester M3 3AW

Tel: 0161 240 8276
Email: [email address]

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