Right to Rectification Policy

GP Practice Policy on the Rectification of Patient Records

1. Purpose & Scope

This policy outlines the procedure to be followed at Old Irvine Road Surgery, Kilmarnock, when a patient, or an authorised representative, requests the correction, completion, or amendment of their health records.

Under Article 16 of the UK General Data Protection Regulation (UK GDPR) and the Data Protection Act 2018 (DPA 2018), individuals have a statutory "Right to Rectification" if they believe the personal data held about them is inaccurate or incomplete.

This policy applies to all clinical and administrative staff, covering all digital records (e.g., EMIS, Vision, Docman), historical paper records (Lloyd George envelopes), and shared electronic environments (such as the Emergency Care Summary - ECS) managed or initiated by this Practice in NHS Scotland.

2. Key Principles: Fact vs Opinion

Health records are unique because they serve as both personal data and a historical, clinical record of care. To maintain patient safety and professional accountability, staff must distinguish between factual errors and disputed opinions.

Factual Inaccuracies

Factual errors are clear-cut and objective. Examples include:

• Incorrect demographic details (e.g., wrong address, misspelled name, incorrect date of birth).
• An entry, test result, or consultation notes saved onto the wrong patient's record (a "mismatch" error).
• An incorrect recording of an allergy or medication which was never prescribed or experienced.

Action: These must be amended/corrected as soon as possible.

Opinions

A patient may disagree with a diagnosis, symptom assessment, or an opinion recorded (e.g., a diagnosis of "anxiety" or a note stating the patient appeared "combative").

Under UK GDPR, a recorded opinion is considered "accurate" personal data if it is an accurate reflection of what the person observed and concluded at that specific point in time, even if subsequent events or investigations prove that initial diagnosis or opinion was incorrect.

Action: Opinions must not be deleted or rewritten unless there is clear evidence of a factual recording error. Instead, the patient’s disagreement must be recorded via a "Statement of Dispute" appended alongside the entry (Section 4 - Option B).

3. The Rectification Procedure:

Receiving the Request

• The patient should put their request in writing to avoid ambiguity.
• The request should identify the specific entry, consultation date, or document that the patient believes is incorrect:
• The request should explain clearly what is currently recorded, what you believe the correct information is, and why.

Investigation

• The person who made the original entry will be consulted wherever possible.
• If the original person is no longer at the Practice, a GP partner(s) will review the entry against the evidence available at the time.

4. Resolving the Request

Following the investigation, the Practice will take one of three courses of action:

Option A: Correcting a Factual Error

If the data is found to be factually incorrect:

• The system will be updated to show the correct information.
• Crucial Safety Rule: The original, incorrect entry must not be completely deleted or made unreadable. It must remain accessible within the electronic system’s audit trail. This is vital because other healthcare professionals may have made subsequent clinical decisions based on the original (incorrect) data.
• For electronic systems, the error should be corrected and a clinical note appended detailing why the change was made, by whom, and when.
• For historical paper records, a single line should be drawn through the incorrect entry (leaving it legible), with the correction, date, signature, and job title written alongside. Tipp-Ex or blacking-out is strictly prohibited.

Option B: Appending a Statement of Dispute

If the person who made the original entry or the GP Partner(s) believe the original clinical opinion or diagnosis was accurately recorded at the time:

• The original entry must not be deleted or amended.
• A permanent, clearly visible clinical note ("Statement of Dispute") will be appended directly to the disputed entry or consultation.
• The note must clearly state that the patient disputes this entry. A brief factual summary of the patient’s perspective should be provided or a reference made to where it can be located within the patients file (e.g. Docman).
• This ensures the record remains balanced, accurate, and compliant with UK GDPR.

Option C: Refusal of Request

The Practice may refuse a request for rectification if it is deemed "manifestly unfounded or excessive" (e.g., highly repetitive requests that have already been investigated and resolved).

• Any decision to refuse must be approved by the Practice Data Protection Officer (DPO).
• The patient will be notified in writing within one calendar month, explaining the reasons for refusal and their right to escalate the matter.

5. Timeframes, Cost, & Third-Party Notification

Response Times

• The Practice will respond to the patient within one calendar month of receiving the request.
• If the request is complex (e.g., involves multiple disputed entries over several years or requires extensive historical clinical review), the period may be extended by up to a further two calendar months.
• If an extension is required, the patient must be contacted within the first month to explain the reasons for the delay and provide a revised deadline.

Fees

• All requests for rectification will be handled free of charge.

Notifying Third Parties

• If the disputed or incorrect information has previously been shared with external parties (e.g., secondary care/hospitals via referrals, NHS National Services Scotland, or insurance companies), the Practice has a legal duty to contact these third parties to notify them of the rectification or the statement of dispute.
• The patient must be informed of who these third-party recipients are, if requested.

6. Conflict Resolution & Escalation

If a patient is dissatisfied with the outcome of their rectification request, they have the right to challenge the decision. The Practice will provide the patient with details of the following escalation pathways:

1. The Practice Complaints Procedure: The patient can submit a formal complaint
2. The Information Commissioner's Office (ICO): The patient has a right to lodge a complaint directly with the UK's independent data authority.
• Website: https://ico.org.uk
• Scotland Office: Information Commissioner's Office, 45 Melville Street, Edinburgh, EH3 7HL