Is it possible for GP/HCP to remove notes without trace?

[Nedmund]

I mentioned something during an appointment and it either hasn't been recorded or it's been deleted when I've followed it up (since I was originally dismissed).

If it's the former, I won't have any proof of this and can only be annoyed at it but would the latter show up? If so, how would I be able to prove this?

No, there’s no edit function in any of the systems we use. Assuming they entered it into the computer, that can’t be deleted by anyone.

If it was a manual record, obviously it’s easier for a page to go missing or be lost.

I don’t know about other systems, but in the one I use (I’m a nurse) it’s impossible to remove records without a trace-the only option is “entered in error” and it shows up crossed out with a red line so that you can still read it. I’m pretty sure that tampering with medical records is a crime. As for it not being recorded, we’re supposed to enter a record when we see someone as quickly as possible, ideally within a few hours so things don’t get forgotten. It can be tricky to get everything in though. I hate to ask, but would your issue seem “significant” to a HCP? If it was part of a larger consultation it might just have not made the record but I appreciate that might be hard to accept.

No ... there is always an evidence trail.

@JennieTheZebra So would the 'entered in error' show on my copy of the records requested?

Although it sounds like it's potentially not entered.

@JennieTheZebraI mentioned something that I didn't know whether to bring up or to see if it went away so it was brought up along with another more pressing issue. This person ran no check up on either issue and dismissed both within no more than 2 minutes (that's not an exaggeration either!). The one I'm more curious about the record for I was told to come back in 6 months if I felt it was still an issue. It has now come up that it's a bigger issue and potentially may have been time sensitive but no confirmation yet. A web search tells me that it should have been checked out then and there as it should have been obvious at the time and another pathway followed.

Sorry I've tagged you twice, it won't let me remove it!

I work in Primary Care. It is sometimes necessary to remove an incorrect entry - for example, a document might be uploaded to an incorrect patient record, or a duplicate document uploaded twice (e.g. If sent via email and post). It's also possible to edit a consultation, or even delete one but these are audited actions and cannot be performed without leaving a (identifiable) trace. However, it's still possible to view the original consultation - it doesn't disappear completely as it's still there in the background, just not immediately visible when a record is opened. Reasons for deleting a whole consult could legitimately be the user wanting to expand their comments - but not knowing how to add/edit them so they resort to a new consultation instead.... believe it or not, clinicians aren't always very tech minded, especially if they're used to a different system as NHS systems in surgeries aren't standardised.

In all of these examples where deletion, rather than editing, takes place, the user is also required to record a reason for their actions. And ideally, they should also be remembering to add an error entry deleted code as good practice.

In short, there will always be a trace left through the audit trail - and audit trails themselves can't be edited.

No. Can't go back and edit, either delete or add.

But surely yours is easily solvable. Was it a consultant you said this to. Then at the next appointment you say : I actually mentioned that to Dr x at my last appointment on 6th July 21, but it wasn't noted in the records. Could you please make sure specifically that it is recorded this time, that I actually asked for it to retrospectively noted.

@Nedmund Yes, on the system I use it would show up if the records were asked for. Entering a record is like an electronic "signature" and so you can see everything that person signed, even if it's wrong/a mistake. Like PP said, there's always an audit trail and I think pretty much all medical systems are the same.

Oh - and if you have a suspicion that information has been removed from your records (as opposed to a clinician forgetting to include it in the first place, which obviously still isn't great because accuracy is all but would be considered human error as opposed to deliberate falsification of records), you are absolutely entitled to query this. As a practice manager I would investigate the audit trail for the particular consultation in question and would be able to see if alterations had been made since it was first submitted. If there were none then it would indicate an oversight (still concerning obviously) but if the consultation had been changed I would then be questioning the clinician as to their reasoning etc. If they couldn't reasonably justify the alteration and if there was any suspicion that information had been deleted in an attempt to cover up clinician error - then a) they would be exceptionally stupid to think they could hide that because it's drummed into all users that everything you do leaves a trace and b) they would be in extremely serious trouble.