We are grateful to everyone who took the time to read our draft guidance and also to those who responded to our consultation.

We received 33 replies and all the Working Group has met to consider these. Where we felt it appropriate we have made changes to our guidance.

Over 40 specific points were raised. Those raised by several people or organisations were:

• All those who responded agreed with our guidance that a note should be added to a record where there is a dispute over the content.
• Some disagreed with our position that in exceptional circumstances it might be agreed that an entry in a paper record should be completely removed or suggested variations to this. We remain unanimous that we cannot state that this will, or should, never occur and so on this point our guidance remains unchanged.
• Some of those agreed with our guidance on deleting entries in paper records felt that we should clarify the circumstances when it might be acceptable to do this and how it should be done. We feel that it would not be appropriate for us to try and do this as the decision should be based on individual circumstances.
• Some felt that our guidance wasn't as clear as it might be. We have made changes and our guidance is now being reviewed and edited by the Plain English Campaign. We hope that it will receive their Crystal Mark for clarity.
• During the preparation of our guidance we had been made aware of the stigma that incorrect or inappropriate comments and opinions in records can cause. We were asked to strengthen our comments on this and we have.
• Some felt that we should produce a separate document for patients, service users and the public and another for professionals. We have divided our guidance into two clear sections but we still feel that it is important that these sections remain together in one document.
• Some people raised matters not directly related to the guidance which they thought the NIGB should provide advice on, for example when a patient seeks treatment but does not want their information recording on an electronic record or who can access what information in records. These are all being considered as possible items on the NIGB future work plan.

We expect to publish our guidance in January 2010.

Ian Hayes

Chair, NIGB Working Group