Guidance ‘wrong’ on amending clinical notes

When the Londonwide Local Medical Committees issued advice to its members on correcting clinical notes it seemed a straightforward matter. Don’t do it – add a correction with a date and explanation.

The only problem is that, according to Paul Cundy, a London GP and chair of the Joint GPs IT Committee, this advice is wrong.

Now the “professional voice of London general practice” may have to back track.

The original advice, issued in August under the title “free text facility on computer notes” said that the Londonwide LMCs had been made aware of a small number of cases where GPs’ notes had been amended using the edit facility.

“Any attempt to amend a contemporary clinical note, even with the best intentions, unless the date of amendment and the reason for it are both explicit, is liable to misinterpretation and criticism and may have clinical governance implications,” it says.

It could even result in a GP being referred under fitness to practice procedures, it adds.

“Our advice is that clinical notes should never be altered, even if this is to correct an obvious error, but that a correction should be added, with the date of the correction, and any relevant explanation.”

But Dr Paul Cundy, a London GP and chair of the Joint GPs IT Committee, the combined IT group of the Royal College of General Practitioners and BMA, said this was wrong and runs counter to the professional guidance endorsed by the Department of Health, BMA and RCGP.

He said: “This is confusing and not strictly true. When you edit an entry you create a new duplicate and the original is retained”

He added: “This is not a new problem and has been covered in good practice guidelines. The Londonwide LMCs need to get it down and get it right.”

Sue Broom, director of communications for LondonwideLMCs Ltd, said she would look into the issue and correct the advice as necessary.