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We were concerned that if incorrect results remained visible there was always the potential for them to be accessed but the caveat missed. We have, therefore, taken the view that any incorrect results should be hidden but not deleted. Should there be a question over care at a later stage the origin results are then available for review. Obviously this is true only for computer held results that are on systems over which we (i.e. the Trust) has management control. Trevor Tickner, Norwich -----Original Message----- From: Mascall, Gary (Biochemistry) [mailto:[log in to unmask]] Sent: 07 October 2003 14:06 To: [log in to unmask] Subject: Re: Amending reports My practice, and understanding, is that the original report, even if incorrect, must remain in the patient record, as someone may have acted upon the results, and to remove it could be "removing the evidence". We make sure the re-issued report clearly indicates that it supercedes the original, and it is these results which are the "correct" ones, asking that this be recorded in the patient's records. An audit I did picked up a few instances where this last point was not done, but subsequent ones have been much better. We had a similar local debate recently about results sent to a Web-browser results reporting system. It was finally agreed that the system holds all results, but if it has been re-reported, has an alert to warn the user, only displays the latest result, and the user can look at the original if they wish. Again felt this was better, as results go out every 10 minutes, so very hard to stop a "rogue" result getting out (normal hence automatically authorised when correct result was abnormal). This is much better than the Pathology system we have, as it only keeps latest results, plus an audit log for 3 months. GP results are treated the same way, and we now know that the GP computer systems we send the results to automatically, store the results by the date received on their system, not by the lab number, so they will have both copies, and once they have been filed, the users cannot remove them easily. Gary Mascall Kiddermisnter Hospital -----Original Message----- From: Ford Clare (RLZ) [mailto:[log in to unmask]] Sent: 07 October 2003 13:44 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 ------ACB discussion List Information-------- This is an open discussion list for the academic and clinical community working in clinical biochemistry. Please note, archived messages are public and can be viewed via the internet. Views expressed are those of the individual and they are responsible for all message content. ACB Web Site http://www.acb.org.uk List Archives http://www.jiscmail.ac.uk/lists/ACB-CLIN-CHEM-GEN.html List Instructions (How to leave etc.) http://www.jiscmail.ac.uk/ ---------------------------------------------------------------------------- ------------------- Any opinions expressed in this e-mail or any attached files are those of the individual, and not necessarily those of Worcestershire Acute Hospitals NHS Trust. This e-mail is confidential and intended for the addressee(s) only. 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