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FDPStreet
Canine II

Delete inaccurate information

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A patient requested a copy of their electronic record, which has been sent to them. They have highlighted some information which was recorded in the past that they consider to be inaccurate and have insisted that this is deleted. Is this possible? I thought not for medico-legal reasons but GDPR seems to indicate that they have that right. If it is possible, how do we go about it?

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Hi Alison,

Due to the importance of the clinical notes that are recorded by the clinician, it is not possible to delete information from here in order to protect both the patient and the clinician.  However, it is possible to edit the clinical notes but R4 will keep a record of the original version as well as the amended version.

To edit the clinical notes, find the date that the notes were entered and click the padlock on the right-hand side.  Delete the item that has been requested.  Although not mandatory, I would recommend that you add that the notes have been amended at the request of the patient.  Click the open padlock to lock the notes again.  Now when you look at the note, the amended version will be displayed but when you hover the mouse over the date, you will see that the notes have been amended.

As a best practice suggestion, I would recommend that you obtain the patient's written instructions to amend their clinical notes and scan a copy of the letter onto the Comms tab in case it is needed in the future.

I hope that this helps.

Regards

Stephen

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stephen_skelton
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Moderator

Hi,

It really depends on what information the patient has requested is deleted and whether or not it is possible to do so.  Can you provide further details as to what section the incorrect information is located in (i.e. clinical notes, patient, record, medical history, etc).

Do not enter any patient identifiable information in your reply.

Regards

Stephen

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Hi Stephen,

It's information in the clinical notes, entered by our hygienist, probably as conversation starters for subsequent appointments, such as patient's daughter is getting married, or they have a holiday home in Spain.

The patient has demanded that this is removed from the notes and our external DPO has said that we shouldn't be recording that kind of information. 

Alison

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Hi Alison,

Due to the importance of the clinical notes that are recorded by the clinician, it is not possible to delete information from here in order to protect both the patient and the clinician.  However, it is possible to edit the clinical notes but R4 will keep a record of the original version as well as the amended version.

To edit the clinical notes, find the date that the notes were entered and click the padlock on the right-hand side.  Delete the item that has been requested.  Although not mandatory, I would recommend that you add that the notes have been amended at the request of the patient.  Click the open padlock to lock the notes again.  Now when you look at the note, the amended version will be displayed but when you hover the mouse over the date, you will see that the notes have been amended.

As a best practice suggestion, I would recommend that you obtain the patient's written instructions to amend their clinical notes and scan a copy of the letter onto the Comms tab in case it is needed in the future.

I hope that this helps.

Regards

Stephen

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