Can anyone who knows about System One...

[skeggysteve]

...answer a simple question?

If a doctor or other medical person puts an incorrect entry on a patients record can it be removed?

[SlidingSideways]

I’m pretty certain it should be able to either be removed, or marked as erroneous so that it no longer shows.
The guy in the office that would know for sure is off today, but can double check if nobody else is any the wiser.

[skeggysteve]

I would be very grateful if you could do that unless someone else answers.

Operations Manager at the surgery told me that it could only be removed by the doc/nurse that made the entry but a week later it's still showing.

[knk]

It can be removed or hidden but there will always be an auditable trail of the information. It is more usual and probably more correct to add a comment that it is an incorrect, or disputed entry.

[skeggysteve]

KnK thanks for that info.

The situation is that I spoke to my wife's diabetic nurse (something I do regularly) last thursday and she has added two entries:
Coded entry Telephone follow up (Xaa4c)
Coded entry Death of husband (Xa7nt)

As I'm very much alive I rang them and was told that only the nurse that made the entry could remove it. I expected it to be removed quickly and of course it has upset my wife so I'm just wondering what my next move should be.

[geeks]

It can be removed, it shouldn't need to be done by the person who issued the marker. Ask to speak to the practice manager, they should be able to ensure it is removed.

[skeggysteve]

geeks are you 100% sure about that? Not doubting you but I want to get my facts right before doing anything.

The practice manager won't take calls but as I said I have spoken with the operations manager who told me that only the nurse that made the entry can remove it.

[SlidingSideways]

I’d be hauling yourself out of your grave and getting hold of a copy of the practice complaints procedure, which will outline how you escalate this.

On the other hand, apparently being dead does have some good tax benefits, so maybe don’t be too hasty

[skeggysteve]

SlidingSideways said:

On the other hand, apparently being dead does have some good tax benefits, so maybe don’t be too hasty

That made me laugh a bit more than it should have done! Thanks.

I don't want to complain as the nurse is very nice and anyone can make a mistake I just want my death to be postponed for a bit.

[Bill]

geeks said:

It can be removed, it shouldn't need to be done by the person who issued the marker. Ask to speak to the practice manager, they should be able to ensure it is removed.

I don't think it can be completely removed but can be "marked in error" which is the same thing from the perspective of someone reading the notes but leaves an audit trail. I wouldn't be surprised if only the person who did the notes can remove it as it's their record of what happened and shouldn't be editable by someone else.

But I'm only a lowly user so don't know what powers admin have.

[skeggysteve]

Bill what you said makes sense I suppose especially the audit trail bit. But you'd think that such a serious error would be treated differently.

[Bill]

skeggysteve said:

Bill what you said makes sense I suppose especially the audit trail bit. But you'd think that such a serious error would be treated differently.

Thinking further into it, I'd be surprised if it can. A big part of it is to prevent people changing the record to cover errors up. Plus, it's only recently that there's been easy access to your own record so there may well not be a system to remove something the patient might find upsetting.

[skeggysteve]

I've just phoned TPP the people that sell System One and even though their website says they don't talk to patients they did answer my question.

Anyone at the surgery that has access can mark the entry as a error and then it can be removed.

[Bill]

skeggysteve said:

I've just phoned TPP the people that sell System One and even though their website says they don't talk to patients they did answer my question.

Anyone at the surgery that has access can mark the entry as a error and then it can be removed.

I've just had a look on a test patient as it was bugging me. I can request a mark in error, which presumably goes to the user in question to do it. On my own notes I just mark it.