Right to Rectification

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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. You may 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 in writing by completing this form and we will need as much information as possible, including dates of entries and what you disagree with. We will then consider the request. If we agree to make a change, we will make it as soon as practically possible.

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 us to amend the entry that you feel is inaccurate, we should not change it if the healthcare 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, healthcare 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.

Medical records are working documents compiled under time pressure and will inevitably contain textual errors. We would encourage service users to only address mistakes in spelling, punctuation and grammar where there is real chance that corrections will alter the meaning of the document.

If you are unhappy with the decision of any healthcare organisation to retain information you wish to have deleted there are some steps, you can take.

In the first instance, you should make a formal complaint through our 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)  https://ico.org.uk/

Tel: 0303 123 1113  opening hours are Monday to Friday between 9am and 5pm (excluding bank holidays)

Right to Rectification

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