All sample legal documents

Medical Records Amendment Request

A completed fictional UK GDPR Article 16 request separating factual rectification from disputed clinical opinion.

Jurisdiction: England and Wales - completed fictional worked example

Download Sample

An editable Microsoft Word version is available from the interactive page.

Important: This sample provides general legal information only and is not legal advice. Check the law, prescribed forms and signing requirements that apply to your exact jurisdiction and circumstances before use.

# MEDICAL RECORDS AMENDMENT REQUEST

Date: 9 January 2025

Parties: From Olivia Bennett, NHS number 943 781 2604, to the Data Protection Officer, Riverside Medical Centre

## 1. Addressee and subject

Dear Data Protection Officer, I request rectification of inaccurate personal data in my Riverside Medical Centre record. The entry dated 16 September 2024 states, 'patient stopped apixaban in July because she forgot doses'. The factual part is wrong: I stopped on 3 September only after the anticoagulation clinic advised me by telephone to do so because of bleeding, and I did not miss doses in July. Please treat this as a data protection request, with a copy to the practice clinical lead.

## 2. Chronology and distinction

I attended the clinic on 3 September 2024; nurse Laura Evans documented the telephone advice in the clinic system that day. On 16 September Dr Patel entered the sentence quoted above. I accept that a clinician may record a clinical interpretation or opinion, and I am not asking the practice to erase a genuine professional opinion merely because I disagree. I am asking it to correct the objectively inaccurate dates, reason, and assertion that doses were forgotten.

## 3. Basis and requested amendment

This request relies on the UK GDPR Article 16 right to rectification and the accuracy principle. Please amend the entry to say: 'Apixaban stopped on 3 September 2024 following telephone advice from the anticoagulation clinic because of reported bleeding; patient disputes that doses were forgotten in July.' If the practice considers the original clinical opinion cannot be changed, please add this supplementary note and clearly mark my account as disputed, rather than silently deleting a clinical record.

## 4. Evidence and deadline

I enclose the anticoagulation clinic message dated 3 September, my pharmacy dispensing history for 1 June to 30 September, and my contemporaneous diary entry. Please acknowledge this request and respond without undue delay and, in any event, within one month of receipt, subject to the applicable UK GDPR rules (and tell me if an extension is lawfully needed). Please also tell me which recipients, if any, will be notified of a correction. If refused, give reasons and the current complaint route, including the option of contacting the ICO.

## 5. Status and signature

Please restrict reliance on the disputed factual statement while this request is considered where appropriate, particularly in medication decisions, and retain an audit trail of any amendment. This letter does not ask for treatment advice or assert that a correction will change my care. Yours faithfully, Olivia Bennett, 9 January 2025.

Create a version for your situation

Create a tailored Medical Records Amendment Request