What can I do if I think my medical records are wrong?
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If you think that something in your medical records is wrong, the Patients Association recommends that you write to the GP or hospital saying what is wrong, and providing any evidence you have which supports your view. Medical records cannot usually be changed, but a note can be added explaining why they are incorrect. It is important that your records are accurate because the treatment you are given may depend on them.
Medical negligence claims usually involve events which took place some time ago, so that clinicians cannot be expected to remember exactly what happened. For this reason both the you and the hospital or clinician will rely heavily on the medical records, which are supposed to be an ongoing summary of the patient’s condition or the treatment provided. The records may be unreliable for many reasons: perhaps because they were done in a rush and fail to include everything which is relevant, or because the clinician omitted to make a note and only realised that omission later, when their recollection was poor.
Very occasionally clinicians include things which they forgot to do at the time but claim to have done to avoid getting into trouble and sometimes records are destroyed or tampered with in order to show that errors did not happen. Falsifying medical records is a crime if it is done with the intention to mislead, and clinicians who are found to have falsified records face being censured or struck off the register. It is not something which a clinician would do lightly.