An error in your medical record can follow you: how to get it corrected

Medical records are used by professionals who may never have met the patient before. An inaccurate entry can influence future diagnoses, prescribing decisions, referrals and assessments of risk. It can also be copied between services, turning one mistake into several matching records.

Understanding the difference between an incorrect fact, a disputed opinion and an accurate record of an earlier mistake is therefore essential.

Some mistakes are administrative. A record might contain the wrong address, telephone number, date of birth or next-of-kin details.

Even apparently minor errors can become significant when information is shared between a GP practice, hospital, pharmacy, mental-health service or another care provider.

The UK GDPR requires personal information to be accurate and, where necessary, kept up to date. The Data Protection Act 2018 describes inaccurate personal data as information that is incorrect or misleading about a matter of fact.

Before asking for a correction, obtain the wording of the entry and identify who holds it.

Some information may be available through the NHS App or another patient portal. If the relevant entry is not visible, the patient can ask the organisation for access to their information or make a subject access request.

A screenshot or downloaded copy can help preserve the wording as it appeared when the problem was discovered.

Different organisations may hold separate records. Correcting a GP record will not necessarily amend a hospital system automatically, and the reverse may also be true.

Patients have a right to request rectification where an organisation holds inaccurate factual information about them.

A factual error might include the wrong date of birth, a medication the patient has never taken or an entry stating that an operation took place when it did not.

Professional opinions are more complicated. A clinician may record a suspected diagnosis, an assessment of symptoms or an opinion based on the information available at the time. The fact that another professional later disagrees does not automatically make the original entry inaccurate.

The record may be accurate because it truthfully records what the clinician thought at that point.

However, the record must make clear that the entry was an opinion or provisional diagnosis rather than a confirmed fact. If the opinion was based on incorrect information, that underlying error should also be addressed so the record is not misleading.

Suppose a GP records a possible condition and later tests establish that the patient does not have it.

The patient may understandably want the original diagnosis removed. However, the earlier entry may need to remain because it explains the investigations, treatment or referral decisions that followed.

The appropriate correction may be a clear later entry confirming that the initial diagnosis was provisional and has now been ruled out.

The important question is not simply whether the original words remain. It is whether the record, read as a whole, gives an accurate and current account.

NHS England says that when inaccurate health or care information is amended, the original entry should not simply disappear.

Other professionals may already have seen and relied on it when making decisions. Retaining the original entry, together with a visible correction, preserves the history of what happened and helps explain earlier care.

For a paper record, NHS guidance says an error should be crossed through with a single line so it remains readable, with the correction and the person’s initials added.

Electronic systems should retain an audit trail showing the original information, the amendment, when it was made and who made it. A retrospective change should include an explanation.

This protects the patient as well as the professional. A correction that leaves no trace could make it impossible to understand how an earlier decision was reached.

A rectification request can be made verbally or in writing, but a written request creates a clearer record.

Send it to the organisation responsible for the entry. Depending on the record, that might be a GP practice, hospital trust, community provider, mental-health service, dental practice or another care organisation.

The request should:

A patient does not need to quote legislation for the request to be valid. Clearly challenging the accuracy of the information and asking for it to be corrected is sufficient.

The organisation should investigate the challenge rather than dismissing it simply because the entry was made by a healthcare professional.

NHS England says the information-governance team should normally consult the professional who entered the information. If that person is unavailable, the matter may need to be considered by a manager, professional lead or Caldicott Guardian.

The ICO says a person can also ask for processing of the disputed information to be restricted while its accuracy is being verified.

How restriction operates in a clinical setting will depend on the circumstances and patient-safety considerations. It does not necessarily mean hiding the information from everyone involved in care. The organisation should explain how it will prevent unverified information from being treated as established fact while the investigation continues.

If the entry could create an immediate clinical risk, such as an incorrect allergy or medication, contact the care provider directly and explain the urgency. Do not rely solely on the ordinary data-protection timetable where patient safety may be affected.

A request for rectification should be handled without undue delay and normally within one calendar month.

An organisation can extend the period by up to a further two months where the request is complex or the person has made several requests. It must explain the extension and its reasons within the initial month.

The organisation may ask for information needed to confirm the requester’s identity, particularly because medical records contain highly sensitive information.

In most cases, there is no fee for exercising the right to rectification.

Correcting the original record may not be enough if the inaccurate information has already reached other healthcare organisations.

Where rectified information has been disclosed to recipients, the organisation must normally tell them about the correction unless doing so is impossible or would involve disproportionate effort.

The patient can ask which organisations received the information and what has been done to update them.

This matters because an inaccurate entry can be copied into referral letters, discharge summaries, shared-care records and clinical systems operated by different providers. Each copy may need attention.

An organisation may decide that the information is factually accurate or that it represents a legitimate professional opinion recorded at the time.

If it refuses to amend the entry, it should explain its reasoning and inform the patient about their right to complain.

Where agreement cannot be reached, NHS England and the NHS Constitution for England support adding a statement to the record explaining that the patient disputes the entry and why.

That statement does not necessarily prove that the original entry was wrong, but it ensures that future readers can see that its accuracy or interpretation has been challenged.

A patient can ask for the statement to be clearly linked to the disputed entry rather than placed somewhere unlikely to be noticed.

For NHS organisations in England, the patient may also contact the Data Protection Officer, information-governance team, Patient Advice and Liaison Service or Caldicott Guardian, depending on the nature of the dispute.

If the organisation maintains its position, the patient can complain to the Information Commissioner’s Office. The ICO will normally expect the organisation to have had an opportunity to investigate first.

Data-protection rights apply across the UK, but NHS complaint structures and service names differ between England, Scotland, Wales and Northern Ireland. Patients should check the privacy notice and complaints procedure of the organisation holding the record.

ConsumerWise’s view is that preserving the history of medical care should not become an excuse for leaving an error unqualified.

There is a legitimate difference between rewriting the past and correcting the present record. A clinician’s provisional opinion may need to remain, but later findings must be recorded clearly enough that nobody mistakes an abandoned diagnosis for a current one.

The practical test is what the next professional will understand when they open the record.

If the correction is buried, disconnected from the original entry or left on another system, the record may remain misleading even though an amendment technically exists.

Patients should not have to repeatedly explain an error that the record itself ought to make clear.