GCC Fitness to Practise Learnings: retrospective changes to records

General Chiropractic Council’s (GCC) Investigating Committee recently considered a case where the registrant admitted making substantial changes to their notes.

Writing on its website, GCC said tht background to the case involved a patient who made a complaint alleging that the chiropractor (the registrant) had injured them in the course of their treatment.

The Clinical Advisor instructed by the GCC did not identify any concerns with the approach to treatment, however they noted that the notes provided by the Complainant and the Registrant differed significantly.

The registrant explained that they had left the clinic where they had treated the patient. The registrant had provided the GCC with a copy of their contemporaneous notes, while the patient had been given notes that had been edited later as part of a handover before the registrant left the clinic. The registrant apologised to the complainant for the confusion.

The Investigating Committee accepted the registrant’s explanation, and noted that he had now changed his practice to specifically highlight any retrospective changes made to clinical notes.

The Committee found that there was insufficient evidence capable of supporting a finding that there had been intentional or dishonest behaviour by the Registrant in respect of his clinical notes.

Learning

Writing on its website, GCC said:

“Although it has always been good practice to highlight any retrospective changes to clinical notes, from the 1 January 2026, it will specifically be part of the Code of Professional Practice.”

Standard J2 in the Code of Professional Practice (2026) states:

J2: (you must) be accountable for keeping patient records up to date, legible, and attributable. Your record must accurately represent each interaction with the patient. Retrospective amendments or additions to patient records must be identified clearly.

“As a result of this specific case, it has become clear that not all digital clinical records systems on the market used by Chiropractors and Clinics have the functionality to show edits and retrospective adjustments made to records.

“You may wish to contact your provider to ensure that this feature will be available for 1 January 2026, or consider a workaround to ensure the accuracy of any retrospective amendments made to patient records.”

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