Dear South London and Maudsley NHS Foundation Trust,

Do you condone clinicians documenting a patients ethnicity, background or religion as a clinical opinion?

Yours faithfully,

S.Jones

Kazeem, Toyin, South London and Maudsley NHS Foundation Trust

Dear S Jones,
Thank you for your email requesting information. Please can you kindly clarify what you mean as it is unclear as to what you are seeking?

Regards

Ms Toyin Kazeem
Archives and Assurance Manager
Information Governance Team

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Dear Kazeem, Toyin,

1. Are statements in clinical records describing a patients race/religion/ethinicity or background considered to be facts or an opinion?

Example
If a clinician employed by the Trust makes a comment about a service users race/religion/background,(Patient is from ____________) and at a later time a patient says this is incorrect, would the Trust support a clinician refusing to amend the record on the basis that it is a clinical opinion?

Yours sincerely,

S.Jones

Kazeem, Toyin, South London and Maudsley NHS Foundation Trust

1 Attachment

Dear S Jones,
Please find enclosed response to your request for information.

Regards

Ms Toyin Kazeem
Archives and Assurance Manager
Information Governance Team

SLaM email is secure and has been accredited by NHS Digital to the same SCCI1596 standard as NHS.net.
Accreditation can be found here: https://digital.nhs.uk/nhsmail/secure-em...

show quoted sections