How to Correct an Error in Medical Records
How to correct an error in medical records on paper and in EDM, what to do on a patient's rectification request and how to word the note.
You entered the wrong treatment date in the patient record. Or you wrote recommendations in another person's record because the wrong window was open on screen. Or a patient reads a copy and says they were described inaccurately. The first instinct is to blot it out, cut it out, overwrite it. The regulations require the opposite.
How do you correct an error in medical records without destroying their evidential value? The answer depends on whether you keep paper or software. Below we cover both, treat rectification of records at the patient's request separately, and show sample correction notes.
In brief
- In paper records you do not delete an entry. You strike through the wrong entry and add a note with the reason for the error, the date and the identification of the person (§ 4(6) of the medical records regulation).
- In an electronic system, changes must leave a trace: who, when and what was changed. Changes outside documented procedures are not allowed (§ 1(6)).
- A patient's request to correct data falls under GDPR (Article 16). We found no separate rectification procedure in the Act on Patient Rights or in the regulation.
- You keep records as a rule for 20 years from the end of the year of the last entry (Article 29 of the Act on Patient Rights), so "deleting an entry" at a patient's request is usually not an option.
- Describe every correction so that years later it is clear what the error was and who fixed it.
The rule: you do not delete an error in medical records
The regulation says this directly, but in two different places and two different forms.
For paper, § 4(6) provides that an entry in paper records cannot be removed from them, and if it was made in error, it is struck through and a note is added giving the reason for the error, together with the date and identification of the person making the note. In addition, § 6(5) prohibits removing a document included in paper internal records, and the pages of paper records are numbered and form an ordered whole (§ 6(1)). A torn-out page leaves a gap in the numbering.
For an electronic system, the matter is governed by the requirements for the software (§ 1(6)). The system ensures the integrity of content and metadata by protecting against changes, except changes made under documented procedures. It also requires identification of the person who made an entry or change, the scope of the changes and the time they were made.
Why so strict? Records are evidence in a dispute with a patient, in an inspection and in proceedings before a professional body. When an entry can be changed without a trace, even a correct entry loses its value. The general rules for keeping records are described in the article on medical records in physiotherapy, and a map of the regulation itself in the text on the medical records regulation.
Correcting paper records: how to strike through and sign
The regulation requires a strike-through, a note giving the reason, the date and the identification of the person. It does not describe the technique of striking through. Our suggestion is simple: strike through with a single line so that the original entry can still be read. Do not use correction fluid or blotting out.
Steps:
- Strike through the wrong passage or the whole wrong entry, leaving it legible.
- Next to or below the entry, add a note: that the entry was wrong and why.
- Enter the date of the note (not the date of the original entry).
- Add the identification of the person: name, professional title, the number of the right to practise (if one has been assigned) and signature (§ 10(3)).
- Add the correct entry. Preferably as a new entry in chronological order, with the date it was made.
Entries in paper records must be legible and in chronological order (§ 4(1)). So do not write the correct version "in the margin" of the earlier entry if that breaks the order.
Correcting EDM: change history
Software usually lets you edit an entry. The law does not forbid changes, it requires that they be made under documented procedures and leave a trace: who, when and what was changed (§ 1(6)). In addition, entries and changes to entries carry the identification of the person making them (§ 4(2)).
What does this mean for you?
- You need a short, written procedure for corrections: who may make them, in what form and how the reason is described. The security of records is to rest on documented procedures (§ 1(5)).
- Ask the software vendor whether the change history is displayed and whether the printout includes corrections. We describe the criteria for choosing software in the article on EDM software for a practice.
- Do not log in to someone else's account to "fix it quickly". The change will be attributed to a person who did not make it, which is a bigger error than the original mistake.
An entry should be made without delay after the service is provided (§ 4(1)). The regulation sets no deadline for corrections, so adopt a simple rule: you correct when you notice the error, and you record the date.
Rectification of medical records at the patient's request
A patient reads a copy of the record and spots a mistake in their own data: a wrong PESEL, an untrue date of birth, an incorrect address. Or they disagree with a description. These are two different situations.
For personal data that is inaccurate in light of the purposes of processing, GDPR applies. Article 16 gives a person the right to have inaccurate data rectified without undue delay and incomplete data completed, including by means of a supplementary statement. The controller (that is, you) answers the request without undue delay, as a rule within one month, and the deadline can be extended by two months if you inform the patient within the first month (Article 12(3)). The principle of accuracy of data also follows from Article 5(1)(d).
How do you do this technically? Correct identification data using the rules from the earlier sections: strike-through with a note, or a change in the system with history. Keep the patient's request together with your reply.
It is harder when a patient challenges an assessment or a description of their health. In the provisions we read we did not find a procedure for "rectifying" such an assessment at the patient's request. You can consider attaching their statement to the records, which fits the idea of Article 16 (a supplementary statement), but without changing your original entry. Disputes over the content of a medical assessment are worth discussing with a lawyer.
A patient may also ask for an entry to be deleted. Article 17(3)(b) GDPR excludes the right to erasure where processing is necessary for compliance with a legal obligation, and the duty to retain records comes from Article 29 of the Act on Patient Rights. We cover issuing copies of records in the article on the request for access to medical records.
Who may make a change and how to describe it
Persons entitled to process data in the records are those practising a medical profession and other persons carrying out auxiliary tasks, on the controller's authorization (Article 24(2) of the Act on Patient Rights). So corrections are made by whoever has the right to make entries in the given records. The note always carries their identification from § 10(3), not the initials "AB".
The description of the reason should be short and specific: "date entered in error", "entry concerned another patient", "wrong side of the body". Wording such as "error" without an explanation does not meet the requirement of giving a reason.
Examples of correct notes
| Situation | Sample note |
|---|---|
| Wrong treatment date | Entry incorrect: treatment date entered in error. Correct date entered below. [date of note], [name, professional title, right-to-practise number, signature] |
| Wrong side of the body | Entry incorrect: the description concerned the left, not the right shoulder. Correct description in a new entry dated [date]. [identification of the person] |
| Entry in the wrong patient's record | Entry incorrect: concerns another patient, moved to the correct records. [date], [identification of the person] |
| Wrong address or PESEL at the patient's request | Data updated at the patient's request of [date]. Previous value struck through. [date], [identification of the person] |
All dates and identifications of persons in the table are placeholders to fill in, not real data.
Most common mistakes
- Correction fluid and blotting out. For paper this directly contradicts § 4(6).
- A torn-out or replaced page. Pages are numbered and form a whole, and a document included in the records must not be removed (§ 6).
- A backdated change with no note. In software, a correction carrying the date of the original entry is only apparent compliance. Record the date of the actual change.
- No identification of the person. A note without a signature and details does not meet § 4(6).
- A correction made on someone else's account. It makes things worse, because it falsifies the author of the change.
- An error involving another patient's data that went outside the practice. If a copy with another person's data reached the wrong person, check the procedure in the article on a data breach and the 72-hour deadline.
Frequently asked questions
Can I blot out a wrong entry in the patient record?
No. An entry in paper records cannot be removed. If it was made in error, you strike it through and add a note giving the reason for the error, with the date and identification of the person making the note (§ 4(6) of the medical records regulation).
Can I simply edit an entry in the software?
The software may allow editing, but changes must be made under documented procedures and leave a trace: who, when and to what extent changed the entry (§ 1(6)). So write a short procedure for corrections and check that the change history is available.
Does a patient have the right to ask for the records to be corrected?
A patient has the right to ask for inaccurate personal data to be rectified under Article 16 GDPR. We found no separate procedure in the Act on Patient Rights or the regulation. In a dispute over the content of a medical assessment, consult a lawyer.
Can I delete an entry if the patient asks me to?
Usually not. You retain records as a rule for 20 years from the end of the calendar year of the last entry (Article 29 of the Act on Patient Rights), and GDPR excludes the right to erasure where processing is necessary to comply with a legal obligation (Article 17(3)(b)). We cover retention rules in the article on archiving medical records. The current text of the regulation is in the Journal of Laws.
How do I word a correction so it is clear years later?
Write what was wrong, why, and what the correct value is. Add the date of the note and the full identification of the person. A good test: could someone who looks at the record years later reconstruct what happened without your help.
Legal status as of: 2 November 2026
Legal basis: Minister of Health regulation of 6 April 2020 on the types, scope and templates of medical records and the manner of processing them (consolidated text Journal of Laws 2026 item 1391), § 1(5)-(6), § 4(1)-(2) and (6), § 6(1) and (5), § 10(3); Act of 6 November 2008 on Patient Rights and the Patient Rights Ombudsman (consolidated text Journal of Laws 2024 item 581, as amended by Journal of Laws 2026 items 26 and 791), Article 24(2) and Article 29; Regulation (EU) 2016/679 (GDPR), Article 5(1)(d), Article 12(3), Article 16 and Article 17(3)(b). We did not check: case law and positions of the data protection authority (UODO) and the Patient Rights Ombudsman on rectifying a medical assessment, criminal and civil liability for falsifying records, or how individual software products record changes.
Last reviewed: 2 November 2026
The TARCZA package contains instructions and a template for the patient record, a therapy plan, a treatment log and rules on storing records. Ready-made templates will not replace the correction procedure you set at your own practice, but they give a solid starting point. See the TARCZA package or compare packages.
Related articles:
- Medical records in physiotherapy
- The patient record in physiotherapy: template and fields
- Medical records regulation in physiotherapy
- EDM in physiotherapy