Altering medical notes

Doctors must take care when amending medical notes to avoid potential charges of evidence tampering.

It is not unusual for a doctor to make a late entry in a medical record. This could occur, for example, when a GP sees a patient but does not immediately have access to notes to make an entry – such as with computer notes.

Another example is when a doctor wishes to expand upon information within the notes whilst a consultation is fresh in mind in anticipation of a future enquiry. Occasionally MDDUS has also encountered significantly re-written notes for other more practical reasons such as when there has been spillage on a case file making originals difficult to work with.

In evidential terms notes are expected to be contemporaneous – they are treated as if they are made at the date/time ascribed. Any note must clearly show the date on which it is made – there must be no suggestion that the entry purports to have been made at an earlier date and time. If the events occurred previously the note should clearly specify this.

Although computer audit trails show when a note is made doctors should not rely on this as confirmation of time and date – the accepted practice is that a note is made on the date stated on the entry.

Whilst there may be an innocent explanation as to why a note was not made at the time stated this can lead to the suggestion that notes have been tampered with and can therefore result in lack of credibility and at worst allegations of tampering. MDDUS has acted on behalf of doctors in such cases facing criminal charges of attempting to pervert the course of justice.

Such charges also attract the interest of the GMC and could land a doctor before a fitness to practice panel facing suspension or possible erasure.

ACTION: Ensure that any changes to medical notes are highlighted with explanation along with the time and date of the amendment. Not to do so could lead to potential charges of evidence tampering.