TABLE OF CONTENTS

• Mark in Error
  • What is “Mark in Error”?
  • What Happens When an Item is Marked in Error?
• Remove from patient record (Full deletion)
  • Approval Process
  • TPP Training
• Which should I use?

When an incorrect item has been entered into a SystmOne patient record (e.g. wrong value, incorrect clinical term, or recorded in the wrong patient record), there are two possible actions:

1. Mark in Error (used in most cases) which removes items from the active clinical record
2. Mark in Error followed by Remove from patient record (full deletion - used only in exceptional circumstances)

Mark in Error

What is “Mark in Error”?

If an error is identified in a patient record, the ‘Mark in Error’ function can be used by the data controller to remove the item from the active clinical record.

In most cases, the data controller will be the service that originally entered the data; however, ownership may differ. For example, GP records may transfer between services when a patient changes GP practice.

If the data is owned by another service, the ‘Request Mark in Error’ function can be used to formally request that the data controller review and consider marking the item in error.

In the majority of situations involving incorrect data, Mark in Error is the appropriate action. It is comparable to striking through an incorrect paper record entry and adding a note explaining when and why it was removed.

What Happens When an Item is Marked in Error?

An item that has been marked in error:

• Is removed from the active patient medical record
• Will not appear in a correctly configured Journal
• Will not appear in standard medical record printouts
• Remains part of the organisation’s held data regarding the individual and may therefore still be included a subject access request (SAR), where applicable or other requests for all data held about an individual
• Provides an audit trail, showing that the item was identified as incorrect and action was taken
• Can be viewed and potentially restored by users with appropriate access rights
  Note: The record node used to view or restore these entries is titled ‘Deleted Items’, although the items have not been permanently deleted.

Remove from patient record (Full deletion)

In rare circumstances, it may be necessary to completely remove an entry from SystmOne.

This permanently removes the item and eliminates the standard clinical audit trail associated with that entry. For this reason it is not used in typical situations involving incorrect data.

• Removal must not be undertaken without careful consideration.
• A removal request must be formally reviewed by the service Caldicott Guardian
  Requests are received as an 'Approve Removal of Patient Data' task
• If unsuitable, the request should be rejected and the item remain marked in error

Approval Process

• The removal request must clearly document the requested reason.

• The Caldicott Guardian must assess whether permanent removal is necessary and proportionate.

• If the Caldicott Guardian submits the removal request themselves, they cannot approve or reject their own request.

• In such cases, a third-party Caldicott Guardian must independently assess the request.

It is strongly recommended that the reviewing Caldicott Guardian has no prior involvement in the original entry wherever possible, to maintain objectivity. Where a third-party Caldicott Guardian is required, it is recommended they should ideally have no relation (direct or indirect, personal or professional) with the service's own Caldicott Guardian.

TPP Training

Caldicott Guardians can locate relevant training items on the TPP Learning Managment System, which includes a video of the request and approval process.

Which should I use?

The scenarios below are examples for guidance only and do not replace local policy or information governance procedures.

• Information entered twice
  Action: Mark in Error - Marking one of the duplicate entries in error is sufficient. When completing the action, select the reason indicating duplication.
• Incorrect information (e.g. wrong value, incorrect term)
  Action: Mark in Error - Mark the incorrect entry in error and select the reason indicating the item was recorded incorrectly.
• Wrong patient record and does not identify the other individual
  Action: Mark in Error likely appropriate - Mark the entry in error and select the option indicating it relates to the incorrect patient. This ensures the record clearly reflects that the event does not pertain to the current patient, while maintaining an audit trail.
• Wrong patient record and identifies another individual e.g. By name
  Action: Deletion may be appropriate - In this scenario, permanent deletion may be considered to reduce the risk of identifiable or sensitive information being disclosed in error (e.g. via a subject access request).