Altering Records

Corrections are sometimes necessary, but they must preserve the original entry and show who changed what, when, and why. Retrospective editing without an audit trail undermines integrity and can constitute misconduct. ^[1][4][5]

How to correct or amend properly

• Use an addendum that is dated and signed (or authenticated), clearly identifies the original entry, and states the reason for change. ^[3][2]
• For factual errors (wrong laterality, incorrect IOP), enter the correct data in a new line; avoid overwriting or deleting. ^[4][5]
• For late entries, mark them as such with the actual date/time of writing and the date/time of the event; explain the delay. ^[3][4]

Practices to avoid and associated risks

References (numbered in text) Why we include references

1. 8. Maintain adequate patient records — General Optical Council Find (opens in a new tab)
2. Patient records — College of Optometrists Find (opens in a new tab)
3. Records Management Code of Practice — NHS England (NHS Transformation Directorate) Find (opens in a new tab)
4. Good medical practice — General Medical Council Find (opens in a new tab)
5. Integrated Addendum to ICH E6(R1): Guideline for Good Clinical Practice (Section 4.9) — ICH Find (opens in a new tab)
6. Risk Alert: Altering clinical records – do’s and don’ts — MDDUS Find (opens in a new tab)