Correcting Medical Records

Level	Source	Core duties relevant to corrections
Commonwealth	Privacy Act 1988 (Cth) – Australian Privacy Principles (APP 12 access, APP 13 correction)	• Take reasonable steps to ensure information is accurate, complete, up-to-date and not misleading. • Respond to a correction request within 30 days; if refusing, give written reasons and advise of the patient’s right to annotate the record. OAIC OAIC
State / Territory	NSW HRIP Act 2002 • Vic Health Records Act 2001 • ACT Health Records (Privacy & Access) Act 1997 • Tas Health Records Act 2021 • Qld Information Privacy Act 2009 • NT Information Act 2002 • WA FOI Act 1992 • SA Information Privacy Principles (IPPS)	Provide parallel rights to seek amendment and require a permanent audit trail; most expressly prohibit deleting or obliterating an entry.
Professional	Medical Board of Australia, Good Medical Practice: A Code of Conduct (2020) – cl 10.4–10.6; RACGP Standards (5th ed.) C2.2	Maintain contemporaneous records; date, time-stamp and sign any alteration; never falsify or back-date notes. Medical Board of Australia

Acknowledge in writing (recommended within 7 days).
Verify the alleged error (check source documents, pathology, correspondence).
Decide within 30 days (APP 13.5); if more time is needed, seek the patient’s consent to extend.
If you agree – add a new dated, signed entry that:
- quotes the original wording in quotation marks;
- states the correction;
- cross-references any changed summary/problem list;
- notifies other providers to whom the erroneous data were disclosed (APP 13.2).
If you refuse (because the information is clinically accurate or reflects professional opinion):
- give written reasons (unless unreasonable to do so);
- advise the patient of their right to lodge a statement of disagreement which must be linked to the disputed entry;
- outline OAIC and local health-complaint avenues. OAIC

Scenario	Corrective action
Minor factual typo (e.g. “left” written for “right”)	• Add an addendum immediately under the original note – “ADDENDUM 25-05-2025 17:30 Dr ___ Should read ‘right’ not ‘left’ — original entry retained for audit.”
Wrong patient file	• Move the entry into the correct chart or segregated ‘miscellaneous/erroneous’ folder with restricted permissions; • Insert a cross-reference in both files explaining the clerical error; • Document steps taken to protect privacy.
Discovering a clinical error	• Do not alter contemporaneous notes; • Add a factual, timestamped note clarifying the error and commence open-disclosure process if warranted; • Record discussions with the patient and any corrective treatment plan.

Never delete, overwrite or back-date entries – audit logs are subpoena-able and deliberate tampering is professional misconduct.

Clinically relevant data cannot be omitted simply because it is sensitive.
Options:
- “Confidential” flag or restricted-access module in the EMR.
- Brief notation: “Sensitive social history discussed – see confidential file.”
- Separate paper record stored in a locked cabinet (rarely necessary and increases fragmentation).
Explain privacy safeguards (encryption, role-based access, MyHealthRecord controls) to reassure the patient.

Case	Key finding	Practical lesson
HCCC v Tan [2024] NSWCATOD 207	GP altered >4 000 records and fabricated referrals; registration cancelled for professional misconduct. bnlaw.com.au	Any retrospective alteration that disguises the clinical truth is likely to end a career.
Medical Board of Australia v Al Raheb (2020)	Doctor reprimanded and conditions imposed for poor record-keeping and privacy breaches. Medical Board of Australia	Non-contemporaneous or incomplete notes attract disciplinary sanctions even without patient harm.
Re A Medical Practitioner (Canberra, 2025)	Tribunal found misconduct where doctor accessed a colleague’s record 14 times without clinical need. ABC	Accessing or amending a record without a therapeutic relationship can itself be misconduct.
Giller v Procopets (2008) VSCA	Court awarded damages for emotional distress under breach of confidence after intimate material was disclosed. List G Barristers	Confidential patient data, if mishandled or disclosed, can found civil liability even outside statutory privacy law.

Wrong-patient entry that is purely administrative (e.g. Medicare number):
- Some EMRs allow administrative delete that still logs metadata; print the audit trail and keep in a secure ‘errors’ file.
Court order or statutory suppression (rare).
In every case, retain an audit trace showing who, when and why. Seek medico-legal or IT advice before proceeding.

Notify downstream recipients (specialists, hospitals, MyHR) if the error may affect care.
Internal audit – ensure practice policy mandates:
- user-unique log-ins,
- locked templates (no mass overwrite),
- routine record-keeping education.
Document the entire correction workflow in the clinical file.
Encourage a learning culture – discuss near-misses at clinical governance meetings.

Privacy Act civil penalty for serious or repeated interference with privacy (up to the greater of $50 m or 30 % of adjusted turnover).
Professional – reprimand, suspension or cancellation (Health Practitioner Regulation National Law s 127, 139E).
Civil litigation – negligence or breach-of-confidence damages (e.g. Giller).
Criminal – fraud charges if falsification linked to Medicare billing (cf Dr Tan).

Policy reference – APP 13; RACGP C2.2.
Receiving a request – log in “Corrections Register”, acknowledge within 48 h.
Assessment meeting – responsible GP + practice manager within 14 days.
Decision & action – complete within 30 days, using standard addendum macro.
Communication – issue ‘correction outcome letter’ + updated referral if needed.
Review – quarterly audit of corrections and EMR logs.