Correcting errors and updating notes

Everyone can make recording errors. The important issue is recognising them quickly, correcting them clearly and ensuring the record shows what happened.

Correct transparently

Do not delete or rewrite entries to hide mistakes. Use the clinical system's process for corrections, amendments or addenda so the record shows the current information and, where needed, why an earlier entry was changed.

If the error has affected patient care, a message, call-back or escalation may be necessary. A corrected note alone might not be enough if others are already acting on the wrong information.

Common reception-note errors

• Wrong patient selected when two names are similar.
• Incorrect phone number, address, date or appointment time.
• Missing urgent wording from the patient's request.
• Stating information as fact when it was reported by someone else.
• Safe-contact instructions recorded in the wrong place or not seen.

When patients challenge a record

If a patient disputes a note, take the concern seriously and avoid arguing at reception. Follow the local process for queries, corrections or disputed entries, and record the patient's challenge.

Correct errors openly and promptly; do not alter records in a way that hides what happened.

Rectification and disputed information