Deleting information from the medical record

The history taking was at the request of the consultant.  While the patient was admitted for a surgical issue you also took a mental status history, at which time you noted that the patient had a significant past psychological history and received counselling following an extra-marital affair that the patient had been involved in, which her husband was unaware of.
 
While attending to another patient the medical records were left on the bedside table of the patient and while flicking through the notes the patient read the history you had recorded and was alarmed to read that a note had been made about her extra-marital affair.  When you returned to see her during a ward round she expressed her dismay that such a note had been made in the medical record and asked for it to be deleted immediately.  She claimed that it had no relevance whatsoever to the reason for her admission and it was quite embarrassing for her.
 
As a hospital doctor you could sympathise with her request but were also concerned about deleting an entry already made.
 
The registrar discussed the matter with her consultant.
 
There may be many reasons a patient requests information recorded in the medical record to be deleted.  The patient may claim that the information recorded is factually incorrect, highly sensitive and embarrassing or the patient simply does not agree with the opinions expressed by medical professionals.
 
In each situation careful consideration is required before any amendment is made to the medical record.
 
Both the privacy legislation and The Freedom of Information Act allow for a person to request an amendment to personal information contained in a document if the information is inaccurate, incomplete, out of date or misleading.  In particular The Freedom of Information Act only permits the obliteration, removal or destruction of a document by an agency (including a public hospital) in particular circumstances, namely whether the prejudice or disadvantage that the continued existence of the information will cause to the person outweighs the public interests in maintaining a complete record of information. 
 
The registrar and the consultant discussed how best to manage the patient’s request.
 
This was not a situation where the information was inaccurate, out of date or misleading.  It was also not a situation which would be rectified by adding a note to the record expressing the patient’s dissatisfaction with the note recorded because the note would still remain in the records.
 
After carefully considering the matter the consultant and the registrar agreed that while being a very thorough note the patient’s mental state was not relevant to the reason for admission, namely a surgical issue and in particular the information about the patients extra-marital affair was not important for her clinical care.  It was decided that the most appropriate way to handle the matter was to delete the reference to the extra-marital affair but maintain the note regarding psychological history and counselling with a further note in the record explaining that the note was amended following discussion with the consultant.
 
The patient was satisfied with this response.
 
The deletion of content from medical records can only occur in very limited circumstances.  If you are considering amending the records in any way you should first seek advice about the most appropriate way to manage that. Our Claims and Legal Services Department can assist you with any queries you may have on 1800 839 280.