Patients may have understandable reasons to want medical records altered, but the rules for practitioners are pretty clear, and are in place for good reasons.
Anna has been your patient for several years. During a recent routine check-up, she mentioned her plans to become a student pilot and she may need to request a medical certificate for her aviation medical examination.
She also casually notes she had eyelid surgery overseas several years ago, which resulted in mild lid malposition and chronic dryness, although she reports no lasting problems.
The next day, she returns visibly anxious. After discovering her history might affect her ability to obtain a student pilot licence, she asks you to remove all mention of the surgery from her medical record.
Situations like these, where patients request the removal of information from their records, can be difficult to navigate. However, there are clear guidelines health practitioners should follow.
Under the Australian Privacy Principles (APPs), patients have a right to request corrections to their health information. However, this doesn’t mean you’re obligated to remove clinically relevant information simply because a patient regrets disclosing it.
APP 10 requires that records are accurate, up to date, and not misleading. APP 13 outlines your obligation to correct records only when the information is incorrect, not when it’s merely inconvenient or uncomfortable for the patient.
In addition to the privacy law requirements, you also have obligations under legislation in some states and territories to keep complete and contemporaneous records. Removing information could create inconsistencies in the patient’s health information and may pose risks in the future if documentation is later needed for continuity of care or a medico-legal review.
Professional codes also reinforce these obligations. The Medical Board of Australia’s Code of Conduct and the National Boards’ Shared Code of Conduct clearly state all practitioners must ensure records are comprehensive and clinically relevant to facilitate continuity of care.
In Anna’s case, a history of eyelid surgery, particularly one affecting her lid function, may be directly relevant to her ongoing eyecare and even her fitness for aviation duties. Omitting this information could compromise clinical safety or mislead others involved in her care.
Accurate information is also in the patients’ best interests. If future symptoms develop or another doctor needs to understand their history, those details ensure safe, informed care. So keeping clear documentation supports both patient safety and your professional responsibilities.
What should you do?
• Don’t delete: Never delete or alter medical records to remove clinically relevant information. In some jurisdictions, deletion is explicitly prohibited. If you made an entry in error, strike through it while ensuring it remains readable, and document why the correction was made.
• Add context: If a patient disputes information in their record but you disagree, document their concerns and the date of the discussion without removing the original entry. This demonstrates transparency and protects both patient and practitioner.
• Limit access if appropriate: Most practice software allows you to mark progress notes as confidential. You can reassure patients sensitive information will only be accessed by practitioners with a genuine clinical need.
• Be clear in your privacy policy: Your privacy policy must explain how patients can request corrections to their information, as required under the APPs. This is both a legal obligation and good practice.
Key takeaways
It’s natural that patients worry about how sensitive information might affect their future, especially when pursuing important goals in their lives – like Anna’s pilot licence.
But as a clinician, your role is to maintain accurate, complete and up-to-date records that support safe care, while complying with your legal obligations.
You can be empathetic and reassuring without compromising your professional or legal responsibilities. When in doubt, document the request, explain your obligations and keep the original record intact.
About the author: Ruanne Brell BA, LLB (Hons) is a senior legal advisor – advocacy, education and research.
