Guidance for patients and service users
Health and care organisations make every effort to keep your records accurate. However, occasionally information may need to be amended about you or your care.
If you think that the health or care information in your records is factually inaccurate, you have a legal right to ask for your records to be amended. For instance, you can ask for your home address to be changed because you moved house. You may also ask for something you feel has been inaccurately recorded, such as a diagnosis, to be corrected. However, it may not be possible to agree to your request.
A request can be made either by speaking to staff or in writing. You may need to provide evidence of the correct details, for example proof of address or change of surname after marriage. The organisation will then consider the request. Where organisations agree to make a change, they should make it as soon as practically possible, but in any event within one month.
Sometimes, you may disagree with information written in your record, but the information could still be factually correct. For example, you may disagree with a diagnosis you were given in the past. Whilst you can still ask the organisation to amend the entry that you feel is inaccurate, an organisation should not change it if the health and care professional believes it is factually correct. There are exceptions to this, for example, where there is a court order.
In cases where all parties agree that the information is inaccurate, it may still be necessary to retain the information. For example, health and care professionals may have taken the information into consideration when making decisions about treatment or care. This information would therefore be needed to justify and explain health and treatment decisions or to audit the quality of care received. You can, however, request for a comment or entry to be made in the record to show that you disagree with the content and what you think it should say.
If you are unhappy with the decision of a health or care organisation to retain information you wish to have deleted there are some steps you can take. In the first instance, you can make a formal complaint through that organisation’s complaints process. If you are unhappy with the outcome of that process then you might consider making a complaint to the Information Commissioner’s Office (ICO) or consider legal action.