Following requests from patients who were experiencing difficulties in getting changes made to their records, the National Information Governance Board (NIGB) has issued guidance on this.

The guidance outlines the purpose of healthcare and social care records and how the NIGB believes problems around the content of records can be resolved, including explaining what people should do and where they get support if they need it.

While the NIGB guidance is aimed at members of the public it also has a section for professionals on how to deal with requests to change the content of records. It makes clear that where a patient contests their record, there is a duty on professionals to reflect in their notes any dispute with a patient about the accuracy of the information. This provides clinical staff with a clear route for resolving any disputes with patients about what is in their record.

The NIGB recognises that good communication is vital in resolving issues like this and in the first instance the matter should be raised with the clinician or social worker responsible for the inaccurate information.

The guidance is to support people who want to get changes made to their records. However, the NIGB also recognises the importance of maintaining the integrity of the record and that information in health and social care records should not be changed or removed without an explanation being recorded.

Harry Cayton, Chair of the NIGB, said:

"The delivery of health and social care is now more than ever before a partnership between the professionals providing care and the people receiving it. Patients and service users expect their records to be an accurate reflection of their care and consultations including their own views. Where there is disagreement about a fact, or opinion, recorded in their notes we want people to know how to set about correcting this. "

Notes to editors

1. The National Information Governance Board for Health and Social Care (NIGB) is an advisory body which was established in October 2007 to support improvements in information governance practice and to monitor information governance trends in both the NHS and adult social care. It became a statutory body as part of the Health and Social Care Act 2008 and on 1 January 2009 it took over the responsibilities of the Patient Information Advisory Group which was then abolished.

Members of the Board are either members of the public, appointed by the Appointments Commission or representatives of organisations which are stakeholders in health and social care information governance.

2. A Working Group of health and social care professionals and public members of the NIGB developed this guidance (PDF, 390Kb) following consultation with patients, clinicians and social workers.