The laboratory must take all reasonable steps to ensure that the health information that it collects, produces, uses or discloses is accurate, complete and up-to-date, and relevant to its functions and activities.
Some factors to consider in determining ‘reasonable steps’ are the likelihood that the information is complete, accurate and up-to-date; whether the information can change over time (e.g. address, date of birth); how recently that information was collected; who provided the information and how the information will be used.
If a laboratory holds health information about an individual and the individual is able to establish that the information is inaccurate, incomplete, misleading or not up-to-date, the laboratory must incorporate the correct information into the health record.
The laboratory should develop protocols for dealing with the changing status of confidence in laboratory data where new knowledge and technology have resulted in significant change in the quality and clinical interpretation of laboratory data.
Where an individual requests a significant change to his or her stored health information, there may be important medical and legal reasons for retaining a complete record. Consequently, the requested changes should be appended, but the original information should also be retained in the record.