“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.
