Correction of data in a register

When a client or patient requests changes to entries in medical records or to client data, an assessment is made of whether there are grounds for correcting, supplementing or deleting the information and whether the information is necessary for the care or the client relationship. Well-founded treatment-related conclusions made by a health care professional will not be changed even if the patient personally disagrees with them. Documentation is also not considered inaccurate if it corresponds to the understanding prevailing at the time it was made, even if, for example, a previously documented diagnosis is later found to be incorrect.

A client may request the correction of a clear error verbally, for example during their next appointment. A request for a correction involving interpretation or another correction made afterwards must be initiated in writing using the data correction request form Rekisteritietojen korjaamisvaatimus (Request for correction of data in a register), specifying whether unnecessary information should be erased or corrected or supplemented with the client’s view. The form must contain the text that is to be replaced erased or supplemented, word for word. It is also advisable to include a copy or printout of the inaccurate information. The client must provide reasons for the changes, erasure or corrections that they request.

If a client wishes to correct information that is visible in the data system and that originates from the Population Information System, they must submit the correction request to the population register authorities.

Implementing a correction

Information that is unnecessary or inaccurate in terms of care or the client relationship is erased from the documents, and incomplete information is supplemented. In an electronic data system, corrections in or erasure of documentation generates a background file. The background file is not visible in client or patient data, but the original text can be retrieved for a lawful purpose, such as in a case concerning a treatment error or for a supervisory authority.

Correcting, changing or adding information in the patient data system also updates the information in the national electronic Patient Data Repository.

If the client’s request to have information corrected is not approved, the client must be given a written response. The response must state the reasons why the request was not approved. If they wish, the client may refer the matter to the Data Protection Ombudsman.