Out-Law / Your Daily Need-To-Know
The Information Commissioner’s Office has published a good practice note to help professionals, including teachers, social workers and doctors, understand how best to comply with the Data Protection Act when recording professional opinions.
“The Data Protection Act gives everyone a right to see information that is held about them including any opinions,” said David Smith, Deputy Information Commissioner. “Professionals need to be aware of this and understand what action is required when an individual challenges one of their opinions.”
In general terms, says the note, the record should make clear that it is an opinion, and detail who gave it and when.
The opinion should be accurate and up to date. It cannot be challenged for inaccuracy under the Data Protection Act simply because it is different to an opinion held by someone else, but factual information contained within it can be challenged.
The record should be structured so that it can show any challenges to the opinion, and it should be adequate and relevant – basically containing enough information to allow the opinion to be correctly interpreted. The more sensitive an opinion, the more explanation or evidence may be needed.
Finally, a policy should be in place detailing how long and for what reasons the opinions should be retained.
As an example, the good practice note cites the case of a patient obtaining a copy of his medical file from his GP and disputing an opinion recorded in it.
In this situation, says the guidance, the surgery should explain that the record must be kept as a true record of the doctor’s professional opinion but that the patient’s comments will be kept clearly on the file.
If the patient also provides convincing evidence that the record includes incorrect factual information then the correct information should be recorded. However a record of the error may need to be kept – if, for example, the patient has received treatment on the basis of the erroneous information.
