Correcting inaccurate hospital medical records

This is a question that comes up frequently and the answer involves both your legal rights and the practical reality of how medical records work.

Your right to rectification:

Under the UK General Data Protection Regulation (UK GDPR), specifically Article 16, you have the right to have inaccurate personal data rectified without undue delay. This applies to NHS and private hospital medical records because they contain personal data and the hospital is the data controller.

Under Article 16 you can also request that incomplete personal data be completed, including by providing a supplementary statement.

How this works in practice with medical records:

Medical records are treated somewhat differently from other types of personal data because of their clinical nature. Hospitals will generally distinguish between two types of inaccuracy.

1. Factual errors. If your records contain a straightforward factual error, for example a wrong date of birth, an incorrect address, a wrongly recorded allergy, or a procedure attributed to you that was actually performed on someone else, the hospital should correct this without difficulty.

2. Clinical opinions and judgments. If you disagree with a clinical opinion recorded in your notes, for example a diagnosis or a clinician's assessment of your condition, the hospital is unlikely to simply delete or change this. A clinician's professional opinion recorded at the time is generally treated as an accurate record of what that clinician thought at that time, even if you disagree with it or even if it later turns out to be wrong. In these cases the usual approach is for the hospital to add a note or supplementary statement to your records reflecting your disagreement or recording the updated position, rather than deleting the original entry.

Deletion is rare:

Hospitals are very reluctant to delete entries from medical records because the integrity of the clinical record matters for patient safety and continuity of care. The usual approach is amendment or annotation rather than deletion. Outright deletion would normally only happen where information is genuinely irrelevant or was recorded in error, not where there is a difference of clinical opinion.

The practical process:

1. Put your request in writing to the hospital, addressed to its data protection officer or the medical records department, or sometimes the Patient Advice and Liaison Service (PALS).

2. Be as specific as possible about what you say is inaccurate and why, and what correction you are seeking.

3. Provide any supporting evidence you have.

4. The hospital must respond without undue delay and in any event within one calendar month, although this can be extended by a further two months in complex cases provided they tell you within the first month.

If the hospital refuses:

If the hospital refuses your request and you believe the information is genuinely inaccurate, you can complain to the Information Commissioner's Office (ICO). You also have the right under Article 77 UK GDPR to lodge a complaint with the ICO and under Article 79 to seek a judicial remedy, though in practice the ICO complaint route is the sensible first step.

If the dispute is really about clinical care or a clinical opinion rather than a data accuracy issue, the NHS complaints procedure or the Parliamentary and Health Service Ombudsman may be more appropriate routes.

Key points to keep in mind:

The strength of your position depends heavily on whether you are challenging a clear factual error or a clinical judgment. The former is straightforward. The latter is much harder and you are more likely to achieve an annotation than a deletion. If you can tell me more about what specifically you want changed, I can give you a more tailored answer on your best approach.