Carol Murray, RHIA, CPHRM, Senior Patient Safety Risk Manager, and Richard Cahill, JD, Vice President and Associate General Counsel, The Doctors Company Show Under the HIPAA Privacy Rule, patients have the right to request amendments to their medical or dental records. Providers have the right to determine if the changes will be made. The record should contain both the patient’s request and the provider’s response. Consider the following scenarios and the guidelines and steps outlined below: Scenario 1During an executive physical examination, a provider asks the patient how many alcoholic drinks he has in a day. Because the patient does not drink every day, he responds that he has about five drinks each week. The provider incorrectly documents “ETOH: 5/day.” Subsequent healthcare providers who have received copies of the physical examination refer to the patient’s “daily” alcohol intake. The patient eventually identifies the source of the confusion and requests an amendment to the medical record. Scenario 2A patient returning for follow-up of back strain due to gardening now insists that the original injury occurred at work and wants the prior visit note changed. Patient RequestsWhen you receive a patient request for any kind of amendment to a medical or dental record, these guidelines can help ensure clear documentation:
Provider ResponseA provider who agrees (or partially agrees) with the patient’s request should take the following steps:
A provider who denies a patient’s request should follow these steps:
The request to file an amendment may be facilitated by providing a form for the patient to complete. The form should include the required information relative to the patient’s request and fields to sign and date the request. For additional assistance, contact the Department of Patient Safety and Risk Management at (800) 421-2368 or [email protected]. Resources 45 CFR § 164.526, Amendment of protected health information. U.S. Department of Health & Human Services, Summary of the HIPAA Privacy Rule The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered. Due to aggressive automated scraping of FederalRegister.gov and eCFR.gov, programmatic access to these sites is limited to access to our extensive developer APIs. If you are human user receiving this message, we can add your IP address to a set of IPs that can access FederalRegister.gov & eCFR.gov; complete the CAPTCHA (bot test) below and click "Request Access". This should only be necessary once for each IP address you access the site from. Request Access for 168.138.169.239An official website of the United States government. If you want to request a wider IP range, first request access for your current IP, and then use the "Site Feedback" button found in the lower left-hand side to make the request. What is request for amendment?Making an amendment request
Section 40 of the FOI Act states a request for an amendment must: be in writing; provide an address where a decision can be sent; specify how the information is inaccurate, incomplete, out of date or misleading; and. specify the amendments you are requesting.
What are 3 things you should not add to a medical record?The following is a list of items you should not include in the medical entry:. Financial or health insurance information,. Subjective opinions,. Speculations,. Blame of others or self-doubt,. Legal information such as narratives provided to your professional liability carrier or correspondence with your defense attorney,. What four items must be included in a record of disclosures of protected health information?It must be signed and dated. It must be written in plain language. It must have an expiration date. It must state the right to refuse authorization.
|