Medical Records and Probity: Accuracy, Late Entries and Alterations
What the GMC, NMC, HCPC and GDC require of your records, the difference between a late entry, a correction and an improper alteration, how to amend paper and electronic notes safely, and what four High Court judgments show about how panels treat altered records.
Short answer: every UK health regulator expects records to be accurate, made at the time or as soon as possible afterwards, and attributable to the person who wrote them. Adding information later is not wrong in itself. What turns it into a probity issue is making a later entry look contemporaneous, changing what was originally written so it can no longer be seen, or adding things that did not happen. Late entries and corrections are safe when they are clearly labelled with when they were made, by whom and why, and the original entry stays visible. Records altered after something has gone wrong are treated as among the most serious honesty concerns a professional can face.
Key takeaways
- Being late is a record-keeping problem. Disguising lateness is a probity problem.
- In the High Court, an amendment that was probably accurate was still capable of being dishonest, because it was undated and unexplained.
- Electronic systems keep an audit trail of who changed what and when. Panels can, and do, compare it with your account.
- The riskiest moments to touch a record are after a death, a complaint, an adverse event or an access request.
- If an improper amendment has already been made, adding more changes makes it worse. Get advice and be open.
This guide sits within our probity in healthcare pillar and our wider fitness to practise guide. It focuses on one thing: what happens when the honesty of a clinical record is questioned, and how to make sure your own records never put you in that position.
What each regulator requires of your records
The wording differs, but the four largest regulators expect the same core qualities. The table quotes the current standards directly.
| Regulator | Standard | What it says |
|---|---|---|
| GMC | Good medical practice 2024, paras 69 and 70 | Records of your work must be “clear, accurate, contemporaneous and legible”. Records should usually include “who is creating the record and when”. |
| NMC | The Code, 10.1, 10.3 and 10.4 | Complete records “at the time or as soon as possible after an event, recording if the notes are written some time after the event”. Complete them “accurately and without any falsification”. Attribute entries to yourself, “dated and timed”. |
| HCPC | Standards of conduct, performance and ethics, 10.1 and 10.2 | Keep “full, clear, and accurate records”. Complete all records “promptly and as soon as possible after providing care”. |
| GDC | Standards for the Dental Team, 4.1 and 4.1.5 | “Make and keep contemporaneous, complete and accurate patient records”. Any amendments must be “clearly marked up and dated”. |
Read together, they produce four tests that any entry has to pass:
Accurate
It records what actually happened, nothing added and nothing invented.
Timely
It is made at the time, or as soon as possible afterwards.
Attributable
It shows who wrote it and when it was written.
Transparent
Any later change can be seen, with the original still readable.
Most record-keeping concerns fail the first two tests: notes that are incomplete, vague or written days late. Probity concerns usually fail the last two: the reader is misled about who wrote something, when, or what was originally there.
From contemporaneous to fabricated: five kinds of entry
Not every later entry is a problem. It helps to see the whole range, from what is expected to what ends careers. The dividing line is not timing. It is whether the reader can see what was done and when.
- Expected
Contemporaneous entry
Written during or immediately after the care, dated, timed and attributed. This is the standard every regulator sets.
- Acceptable if labelled
Late entry
Written later because you could not record it at the time. Safe when it is clearly marked as a late entry, with the real date and time of writing, the time of the event it relates to, and why it is late.
- Acceptable if labelled
Addendum or correction
Adds a missing fact or corrects a genuine error. The original stays readable, and the change is dated, signed and explained.
- Probity concern
Disguised amendment
Accurate or not, it is inserted so that it looks part of the original record, or the original is overwritten or removed. The reader is misled about when it was written.
- Serious dishonesty
Fabricated entry
Records care, observations, conversations or checks that did not happen, or attributes an entry to someone else.
The step from the third to the fourth level is the one that matters most. It can be taken in seconds, often by someone who believes they are only adding true information. The case law below shows why that belief is not a defence.
Anatomy of a safe late entry
Here is how a properly labelled late entry looks. The example is fictional, but every element comes from the regulator standards above and NHS England guidance on amending records.
1LATE ENTRY. 2Written 14/03/2026 at 16:40, 3relating to care given 14/03/2026 at approximately 09:15.
4Reason for delay: called to a cardiac arrest on the adjacent bay immediately after the assessment.
5On review at 09:15, patient alert and orientated, reported pain 4/10 in left hip. Analgesia given as prescribed. Advised to call for help before mobilising. 6Fall-risk assessment not repeated at that time; repeated now and recorded separately.
7A. Nurse, RN, PIN [number]
- Labelled. Anyone reading knows at once that this was not written at the time.
- Real time of writing. Not the time of the event. On an electronic system, the system time stamp should match.
- Time of the event. Stated separately, and honestly approximate if you are not sure.
- Reason. NMC Code 10.1 expects you to record that notes were written some time after the event. A short reason makes the delay understandable.
- Only what happened. No detail you did not actually observe or say. If you are unsure, say so rather than reconstructing.
- Gaps admitted, not filled. What was not done is recorded as not done.
- Attributed. Name, role and registration, as the NMC Code and Good medical practice expect.
Same facts, two outcomes. A GP sees a patient with chest pain and writes a brief note. Three weeks later, the patient is diagnosed with a serious condition. The GP remembers asking about breathlessness and wants the record to show it.
Version A: the GP adds a new entry dated three weeks later: “Additional note, written [date]. On reflection I recall asking about breathlessness at the consultation on [date]; patient denied it. Not recorded at the time.” This is transparent. It may be questioned, but the reader can judge its weight.
Version B: the GP edits the original consultation note to add “denies SOB”. The note now reads as if it was written on the day. Even if the GP’s memory is correct, this is the pattern the High Court examined in Rogers, below.
How to correct a record properly
NHS England guidance on amending patient and service user records, last updated in May 2026, sets out the expected method. Local policies add detail, so always follow your organisation’s procedure as well.
Strike, sign, explain
Put a single line through the error so it can still be read, initial it, date it and write the correct information. Never use correction fluid, scribble out, tear out pages or rewrite a page.
Add, never overwrite
Use the system’s amendment function or add a new linked entry. The guidance expects systems to keep an audit trail showing what was typed or added and when. The original entry must not be deleted.
- Correct promptly. The guidance says mistakes should be corrected straight away, or as soon as possible after you realise, with a full explanation.
- Do not change accurate information because a patient disagrees with it. If information is factually correct, the guidance says it should not be changed. A patient can instead ask for a note recording their disagreement.
- Patients have a right to request rectification. Under Article 16 of the UK GDPR, a patient can ask for inaccurate personal data to be corrected. Organisations should respond within one month, usually through their information governance team rather than the individual clinician.
- Deletion is exceptional. Information is removed only in rare cases, through a formal process, not by an individual clinician editing notes.
The audit trail: why disguised changes are found
Many professionals still think of the record as the words on the screen. Regulators and courts do not. An electronic record carries a second layer: who logged in, when each entry was created, when it was changed and what it said before. A paper record has its own clues: ink, handwriting, position on the page, and copies already sent elsewhere, such as referral letters, prescriptions, discharge summaries or charts photographed for an incident review.
When a concern is investigated, the record is compared against these independent sources. In the cases below, tribunals relied on the timing of entries, the contents of other documents and the evidence of colleagues to decide what had really been written and when. An explanation that does not fit the audit trail damages your credibility on everything else.
“Patient denies breathlessness. Advised to return if worse.”
Original entry created on the day of the consultation. Text added to it weeks later, under your login, shortly after a serious diagnosis.
The five moments not to touch a record without advice
In practice, improper amendments cluster around a small number of situations. These are the moments when the temptation to tidy up a record is strongest, and when any change will be scrutinised most closely.
After an adverse event or death
The record of what you did before the outcome is now central evidence for any review, inquest or claim.
After a complaint
Adding detail now looks like building a defence, however genuine your memory.
After an access request
A subject access request or a request under the Access to Health Records Act 1990 for a deceased patient brings the criminal offence above into play.
Before an investigation or inquest
Records requested by an employer, coroner, regulator or legal team must be provided as they are.
When a colleague raises a concern
Questions about your care are the moment to reflect and be open, not to revisit the notes.
In each of these moments, the honest route is the same. Leave the existing record as it is. If something genuinely needs adding, write a clearly dated additional note only after taking advice from your defence organisation, union or employer, and say in it why it is being added now. Being open about what happened, rather than adjusting the record of it, is also part of your professional duty when a concern arises.
Related courseDuty of Candour: being open after something goes wrong→What the courts have said about altered records
The following judgments are all available in full from the National Archives. Each one adds a different lesson. A further case, involving falsified observation charts, is covered in our probity case files.
Moneim v General Medical Council [2011] EWHC 327 (Admin)
The facts. A GP made retrospective amendments to patients’ records over several years. The amendments followed events such as patients deteriorating, emergency admissions, a death and critical emails from his partners. A fitness to practise panel found dishonesty in relation to six patients and suspended him for 12 months.
The outcome. The High Court quashed the dishonesty finding for one patient because of confusion in the evidence, but upheld the other five findings and the 12-month suspension.
The lesson: the judge identified two different ways an amendment can be dishonest. It can be dishonest because its content is false, or because it was made for an improper motive, such as making your earlier care look better, even if the content is true. The court applied the old legal test for dishonesty. Since 2017, panels apply the Ivey test, explained in our guide to dishonesty allegations, but the two routes to a finding remain the same.
R (Rogers) v General Medical Council [2024] EWHC 567 (Admin)
The facts. Days after learning that a patient he had seen for chest pain had been diagnosed with cancer, a GP made substantial additions to the notes of two earlier consultations. The additions were undated and unexplained, so they appeared to be part of the original records. The patient later died. The GMC’s own expert described the conduct as deplorable. The GMC’s case examiners decided not to refer the dishonesty allegations to a tribunal, largely because other records suggested the additions were probably accurate.
The outcome. The patient’s partner challenged that decision by judicial review. The High Court quashed the case examiners’ decisions on three allegations and sent them back to be reconsidered. It held that the case examiners had been wrong to treat the likely accuracy of the entries as answering the allegation that they were made to avoid criticism. The timing, the scale of the changes, the absence of any date or explanation and the failure to disclose them were all relevant.
The lesson: “It was true” is not a complete answer. An accurate addition disguised as a contemporaneous note can still support an allegation of dishonest motive. The case also shows that case examiner decisions not to refer, explained in our guide to fitness to practise investigations, can be challenged.
Demanya v General Medical Council [2025] EWHC 247 (Admin)
The facts. An emergency department doctor assessed an elderly patient with signs of sepsis overnight. The patient died the following day. A tribunal found that the doctor had retrospectively added antibiotics to the prescription chart and catheterisation to the treatment plan, knowing they had not been part of his original plan, and had crossed out antibiotic prescriptions without a valid reason. A nurse gave evidence that she saw him cross out the prescriptions. The tribunal found the conduct dishonest and erased him from the register.
The outcome. The High Court dismissed his appeal. It held that the tribunal had not decided the case on impressions of the witnesses, but by testing the accounts against the contemporaneous records, the timeline and the other evidence, and that its findings were obviously reasonable.
The lesson: after a patient’s death, the original record is the central evidence of what was decided and when. Paper charts are not safer than electronic ones: colleagues notice, and the timeline exposes changes.
PSA v NMC and Offier [2024] EWHC 691 (Admin)
The record charges. Among other charges, a nurse was found to have signed a colleague’s initials on a patient’s medical record. The panel did not find that this was dishonest, did not find that it amounted to misconduct, and found a separate allegation of recording antibiotics that had not been given not proved.
Why it matters. The appeal itself was about other dishonesty, in an agency application and a breach of interim conditions, and the court sent the sanction back for reconsideration. But the record charges illustrate a real point: a record irregularity is not automatically dishonest. The regulator must still prove what you knew and intended.
The lesson: do not assume the worst, and do not concede dishonesty you do not accept. Equally, signing as or for someone else is never good practice. Our dishonesty guide explains how panels decide state of mind.
Two routes to a records dishonesty finding
The Moneim and Rogers judgments make a distinction that every clinician should understand.
Dishonest because it is false
The entry records something that did not happen: an observation not taken, advice not given, a drug not administered.
The question: is the content true?
Dishonest because of why and how it was made
The content may be true, but it was inserted so that it looked original, to make earlier care appear better or to avoid criticism.
The question: what impression was the record designed to give?
Route 2 surprises people. Its logic is simple. A record is not only a list of facts. It is also a statement about when those facts were known and written down. Disguising a later entry makes that statement false.
Poor records and dishonest records are treated differently
Many fitness to practise cases involve records without any suggestion of dishonesty. The HCPC publishes a case study in which an occupational therapist failed to complete case notes, assessments and care plans across nine cases. The panel found misconduct, describing a reckless disregard for the risk to vulnerable service users, noted there was no evidence of remediation or insight, and imposed a six-month suspension. Poor record keeping can be serious on its own. But how it is assessed and remediated is different.
| Question | Poor record keeping | Dishonest record keeping |
|---|---|---|
| Typical concern | Notes missing, incomplete, illegible, vague or very late | Entries disguised, overwritten, backdated or fabricated |
| What it raises | Competence, safety and sometimes misconduct | Honesty, integrity and public trust |
| Remediable? | Generally seen as remediable through training, audit and supervision | Much harder. Panels look for deep insight into why honesty matters, and dishonesty in records can lead to erasure |
| Evidence that helps | Record audits, supervisor feedback, completed training, templates you now use | Full and early acknowledgement, reflection on the reasons for the conduct, evidence of probity learning and sustained honest practice |
The practical point: a gap in your notes is much easier to address than an attempt to hide it. Our guide to evidence of remediation explains how to evidence improved record keeping, including record audits.
If an improper amendment has already been made
Some readers will recognise their own conduct in the cases above. If you have changed a record in a way that was not transparent, these steps are about limiting harm and acting with integrity from this point. They are general information, not legal advice.
- Make no further changes. Do not try to reverse, tidy or explain the amendment by editing again. Every change leaves a trace.
- Get advice before anything else. Contact your medical defence organisation, indemnifier or union. Records issues interact with complaints, claims, inquests and data protection law.
- Be honest when asked. If you are questioned by your employer, an investigator or a regulator, do not repeat or defend an impression you know to be misleading. Later inaccuracies are often treated as more serious than the original act.
- Consider your disclosure duties. Depending on your regulator and circumstances, you may need to tell your employer or regulator. Our guide to self-referral and disclosure explains when.
- Reflect on why it happened. Fear of criticism, panic after an adverse outcome and workload pressure are common drivers. Panels look for insight into the cause, not just regret. See our guide to writing a fitness to practise reflective account.
- Build evidence of change. Structured probity learning, record audits and supervision can all form part of a remediation plan.
Probity for Healthcare Professionals
Honesty in clinical records, late entries and amendments, alongside declarations and the duty of candour. Assessed, with a CPD certificate for your remediation portfolio.
Completing a course does not change or predict any regulator’s decision. Courses are educational and support your own reflection and development.
A four-question check before you change any record
Before adding to or changing any entry that is not your current one, run through these questions. If any answer is no, or you are not sure, stop and take advice.
Will a reader see that this was added later?
It must be labelled, dated and timed as a later entry.
Will the original wording remain visible?
Nothing overwritten, deleted or obscured.
Am I recording only what actually happened?
Not what should have happened, and not what I now think probably happened.
Would I be comfortable explaining this change to the patient, my employer and my regulator?
If it would be uncomfortable after a complaint, death or access request, it needs advice first.
Frequently asked questions
Can I add to a patient’s notes after the event?
Yes, if you need to. Every regulator expects records to be made at the time or as soon as possible afterwards. A later entry should be clearly labelled as late, with the actual date and time of writing, the time of the event it relates to and the reason for the delay. The NMC Code specifically expects you to record when notes are written some time after the event.
Is it dishonest to amend a record if the new information is true?
It can be. In Rogers v GMC (2024), the High Court held that the likely accuracy of undated, unexplained additions did not answer the allegation that they were made to avoid criticism. What matters is whether the change was transparent. A clearly dated additional note is very different from an addition disguised as part of the original.
How should I correct a mistake in paper notes?
Draw a single line through the error so it can still be read, initial and date it, and write the correct information. Never use correction fluid, scribble over entries or remove pages.
How should I correct a mistake in electronic records?
Use the system’s amendment function or add a new linked entry explaining the correction. NHS England guidance says the original entry must not be deleted, and expects systems to keep an audit trail of changes.
Can a patient make me change their records?
A patient can ask for inaccurate information to be corrected under the UK GDPR right to rectification, and organisations should respond within one month. But NHS England guidance says information that is factually correct should not be changed. The patient can ask for a note recording their disagreement instead.
Is it illegal to alter medical records?
Altering, erasing or concealing information to stop it being disclosed to someone who has made a subject access request and is entitled to it is a criminal offence under section 173 of the Data Protection Act 2018. More generally, dishonest alteration of records is treated as serious professional misconduct by every health regulator.
Can the GMC or NMC see when I changed a record?
Electronic clinical systems keep audit trails showing who created or changed an entry and when. Investigators and tribunals can obtain this information and compare it with your account. Paper records can be examined against other documents and witness evidence.
Will I be struck off for poor record keeping?
Poor record keeping without dishonesty is usually treated as remediable, although it can still lead to sanctions such as suspension where it puts patients at risk and there is no insight or remediation. Dishonest alteration or fabrication of records is far more serious and can lead to erasure or striking off.
Is signing a colleague’s initials on a chart dishonest?
Not automatically. The regulator must prove what you knew and intended. In PSA v NMC and Offier (2024), a panel found a nurse had signed a colleague’s initials but did not find it dishonest or misconduct. It is still poor practice, because every entry should be attributable to the person who made it.
Primary sources
- GMC: Good medical practice 2024, Domain 3, paragraphs 69 to 71
- NMC: The Code, section 10
- HCPC: Our expectations for your record keeping
- HCPC: Case study, failure to maintain adequate records
- GDC: Standards for the Dental Team, standard 4.1
- NHS England: Amending patient and service user records
- Data Protection Act 2018, section 173
- Moneim v General Medical Council [2011] EWHC 327 (Admin), National Archives
- R (Rogers) v General Medical Council [2024] EWHC 567 (Admin), National Archives
- Demanya v General Medical Council [2025] EWHC 247 (Admin), National Archives
- PSA v NMC and Offier [2024] EWHC 691 (Admin), National Archives