Amendment of patient medical records under the FOI Act

by | Oct 24, 2016 | Health Blog

The court commented that there are difficulties in justifying amendment of medical records. A person’s medical file is “intended to contain a complete record of the individual’s various conditions, illnesses, medical events, treatments and hospital admissions”.

Under the Freedom of Information Act 1992 (WA), a person has the right to apply to a government agency to amend any inaccurate, incomplete, out of date or misleading information personal information in their medical records.

An agency may amend personal information by doing things such as striking out or deleting information, or inserting a note in relation to information. Information, however, will only be completely erased or destroyed if its continued existence causes a person prejudice or disadvantage that outweighs the public interest in maintaining a complete record.

In the recent case of Morris v Information Commissioner at WA Office [2016] WASC 336, a woman appealed against the decision of the Information Commissioner to reject her application to amend her personal records. The woman had initially applied to have medical diagnoses, including schizophrenia and an anxiety disorder, by various medical professionals over a period of twenty years removed from her medical records. This was on the grounds that the diagnoses had been false or inaccurate, preventing her from finding full time work. The Commissioner had dismissed her application for lack of substance.

The woman’s appeal was ultimately rejected by the court. The evidence before the court did not establish that her medical records were inaccurate, incomplete, out of date or misleading. Neither did the evidence prove that she had never suffered from schizophrenia or an anxiety disorder.

The court commented that there are difficulties in justifying amendment of medical records. A person’s medical file is “intended to contain a complete record of the individual’s various conditions, illnesses, medical events, treatments and hospital admissions”. The fact that records may contain contested opinions of medical professionals does not necessarily mean that the records are inaccurate or misleading. Objective facts in records can be assessed against evidence as either right or wrong. An opinion, by comparison, is not objectively right or wrong and medical experts can validly arrive at different conclusions. Furthermore, an opinion is not necessarily inaccurate, incomplete or misleading merely because it is based, in part, on incorrect factual statements.

A person’s medical records are intended to document their medical history, and may contain a range of factual information as well as medical opinions. Based on the court’s comments in Morris v Information Commissioner at WA Office, a person’s medical records will only be amended where there is clear objective evidence that the information is any inaccurate, incomplete, out of date or misleading.

Oscar Dellanna

Oscar Dellanna