Corrections, late entries and wrong-record risks

Errors occur in records, uploads, measurements, orders, prescriptions, attachments and handover notes. The immediate risk is the original error; the secondary risk is how staff respond.

If a record is wrong do not erase, overwrite, backdate, hide or quietly "tidy" it. Follow your local correction procedure so the practice can identify what happened, protect the patient and keep a clear audit trail.

Examples that need escalation

• Wrong entry: information is added to the wrong patient record.
• Wrong upload: an image, prescription or letter is attached to the wrong profile.
• Wrong measurement: a PD, height or frame measurement is entered incorrectly.
• Wrong order: an order has been submitted using unclear or incorrect information.
• Late note: important information was not recorded at the time.
• Confidentiality concern: information may have been seen, sent or disclosed to the wrong person.

What good correction behaviour looks like

Act promptly. Notify the person or team named in local procedure. Record the facts: what was wrong, when you noticed it, what action you took and who will follow up.

Avoid blame, speculation or private commentary. The purpose of the entry is to make the record accurate and understandable, not to protect reputations or tidy the narrative.

If the error could affect the patient’s appliance, care, referral, privacy or a complaint, escalate urgently. The practice may need to contact the patient, pause an order, amend a record, report an incident or consider candour and complaint duties.

Corrections, audit trails and incidents

Errors need visible correction, not quiet tidying. Preserve the trail and escalate early.