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Legal matters

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Amending medical records

9 replies

51howdidthathappen · 06/12/2015 14:59

Hi.
Does anyone know if a family member amending amending another family members medical records is illegal?

OP posts:
didyouwritethe · 06/12/2015 15:29

Sounds like it would be. I'll be interested to hear.

51howdidthathappen · 06/12/2015 17:47

The person doing the amending is a CPN. Just can't find anything on the net.

OP posts:
HarrietSchulenberg · 06/12/2015 17:50

So is the CPN a medical professional who is not involved in the care of the person whose records were amended?
If so then yes, the amendments are illegal.

RubberDicky · 06/12/2015 18:01

Yes, medical records are a legal document and should not me 'amended' in any way. Even the person who originally wrote the entry in the notes should not go back and change it - just add a correcting note later if they realise they made a mistake so the whole trail can be seen. It is definitely illegal.

AnchorDownDeepBreath · 06/12/2015 18:14

I was about to write what Rubberdicky did. You cannot amend medical records - you can simply add correctional notes where necessary - and this should only be done by medical professionals who are actually treating the person.

I'm presuming that the CPN isn't treating the family member?

RubberDicky · 06/12/2015 18:38

The more I think about this the more concerning I think it is. Could end terribly for the healthcare professional(s) whose notes have been tampered with! Potentially career ending stuff. Please report your concerns to their team leader, OP

RubberDicky · 06/12/2015 18:39

Not to mention it might impair the patient's care if decisions are made based on false entries!

Ohtobeskiing · 06/12/2015 18:44

Why is the CPN accessing their family members medical records? Was the family member asked for consent for the CPN to access the records and was consent given? Has the patient (family member) asked for the records to be changed?

It is a situation fraught with problem!

51howdidthathappen · 06/12/2015 20:36

The patient/family member is cared for at home, no capacity. The CPN another family member, is not treating the family member. It is recorded in the notes that the team were aware notes had been removed and amended. I have no idea what the amendments were. I have emailed the GP.
Thanks all.

OP posts:
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