1/14/2024 0 Comments Doctor discharge letter template![]() ![]() It may help when recording information to indicate where something is your opinion rather than a confirmed diagnosis. Retaining the original diagnosis does not make the record inaccurate, so it is important that this is not amended. For example, there may be an initial working diagnosis which was, at the time of entry, clinically possible, but is later ruled out with a different confirmed diagnosis. There may be times when information was correct at the time the entry was made but has since changed. However, it is good practice to give patients and service users the opportunity to have an entry put into the record to say they do not agree with a particular part and why. If you believe that the amendment request concerns health or care information that is factually accurate, you should not amend the record.
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