I always worry that any incorrect result (however contradicted) in a
patient's notes could at some time induce Dr Murphy's law into action,
risking misinterpretation, perhaps misdiagnosis & mistreatment.
Before removing the report from the notes, I would ask permission of one of
the patient's Medical team, and apologise for the error.
I would also write a signed comment in the patient's Notes, again
apologising, & stating what has been removed.
And complete an "incident form" in the lab.
Best wishes,
Les
> From: "Ford Clare (RLZ)" <[log in to unmask]>
> Reply-To: "Ford Clare (RLZ)" <[log in to unmask]>
> Date: Tue, 7 Oct 2003 13:43:41 +0100
> To: [log in to unmask]
> Subject: Amending reports
>
> I would be interested to learn what procedures different labs employ for
> correcting results that have been reported incorrectly. Is the incorrect
> paper copy removed from the notes or left in situ with some annotation to
> indicate that it is incorrect? If it is removed does this constitute
> tampering with the patient record? What about GP results?
>
> Many Thanks
>
> Clare Ford
> Principal Biochemist
> Royal Shrewsbury Hospital
>
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