I hear from so many physicians about how much they love documenting in the medical record. In fact, if they could do it every waking hour, they would.
Just kidding.
Today, patients have easy access to their medical records and test results.
What happens when they disagree with what you wrote? Do you have to correct it? What happens if you disagree with the patient’s interpretation?
HIPAA details a process that must be followed. Here we go.
The guiding principle is that under HIPAA, patients have a right under Code of Federal Regulations §164.526 to request an amendment of their medical record, but the provider decides whether to agree. Regardless, the provider must timely respond to the request.
The first step is to ascertain if a valid request for record amendment was made.
The request must be in writing and signed by the patient or their personal representative (eg: guardian). Note, an attorney is not considered a personal representative of the patient. The patient should sign your organization’s amendment request form. What, you say, you don’t have such a template ready to go. Here is a template from Mag Mutual.
Next, analyze whether the patient has a point. Was a mistake made? Is the request inappropriate? You will need to decide whether to fully accept the amendment, partially accept, or deny the amendment.
Third, you need to respond to the request.
If you fully or partially accept the request, you will have to notify the patient within 60 days. If you deny the request, you have to notify the patient within 60 days. In other words, you have to respond to the patient within 60 days. If for some reason, you are unable to give a timely yes or no, you must notify the patient in writing, and the code allows for a one-time 30 days extension. In notifying the patient, you must give the reason for the delay (and the need for an extension), and the date when action will be taken.
OK, what are the mechanics if you accept the request for an amendment?
- Note in the record, the record has been amended. Place a copy of the amendment in the record or provide a reference in the record as to where the amendment is located.
- Notify the patient of the acceptance and that you will send the update to those individuals or organizations identified in the original amendment request.
- If other individuals or institutions had received the “before” medical records, obtain the patient’s written authorization to send them the “after” copy of the updated records.
What are the mechanics if you deny the request for an amendment?
- You need to send the patient a denial letter, including the reason the amendment was denied.
- The letter must include verbiage that the patient has a right to submit a written statement contesting the denial with an explanation of how the patient may file that statement.
- The letter must include verbiage explaining the patient can have the original amendment request and physician denial added to their record, instead of submitting a written statement of disagreement.
- Finally, the letter must include a statement of how the patient may file a complaint with the provider or Secretary of US Dept Health and Human Services. The description must include the name and title and phone number of the contact person for complaints.
Reasons for denial may include:
- The Protected Health Information (PHI) was not created by the facility receiving the request. For example, the original record might have been created at some other office/facility.
- The PHI is not part of the patient’s “Designated Record Set.” For example, something other than the patient’s medical or financial records (such as a separate labeled file to emails related to conflict over billing).
- The PHI is not available to the patient for inspection as noted by federal law (eg. Psychotherapy notes)
- PHI is accurate and complete. Not surprisingly, this will be the most common reason for denial.
- Or something else.
After denial, the patient still has options.
They may submit a written statement of disagreement. The provider may prepare a written rebuttal to the statement. The provider must submit a copy of the rebuttal to the patient.
Confusing?
This is what goes into the record post-denial.
- The patient’s signed request to amend the medical record.
- The provider’s denial letter.
- The patient’s statement of disagreement, if any.
- Provider’s rebuttal, if any.
Final thoughts. This is codified in HIPAA. If you let things slip, it could escalate into a complaint to OIG at Department of HHS, with fines and penalties.
Don’t kill the messenger.
What do you think?
I have had only one request to change a record when I was in practice. I do not remember all of the details at this time, but the patient was requesting a change of my opinion not of any facts that were in the record. It may have been related to the lack of any objective, significant, legitimate pain complaints, based on the history and the physical exam. We had patients waving xray films purporting to show “bad findings”, but the correlation back to history and physical exam was lacking .
I personally had to request a change in a medical record, that said that I had previously been pregnant, when going in for a cholecystectomy. I am male so it was easy to get that corrected.
But I have seen numerous minor errors in medical records and it is almost impossible to get them changed, so I don’t try any longer. I just point it out to the next physician that I see. They enter it in their record. But it does not over write what is already there.
Then depending upon who is reading the record, specialist, nurse, nurse practitioner, they may or may not see the correction or updated entry. So I will point that out to them and anyone else that comes along to provide care to me. As long as I am mentally competent this is fine. But what if I was not?
Getting old drugs that I am no longer taking, removed from the record is impossible.
While it would be nice to have an accurate record, there is seemingly little concern anymore about the accuracy of information.
If a bad outcome develops, the attorney’s will argue the value of that information in court.
But as my chief used to say, the first victim in a malpractice case is the truth!
No one seems to care any more if records are accurate or not. Sad.
Being on the other end and fighting a malicious record by my doctor, it takes about 4 years to get it before a court, federal individual medical record, and fighting it risks of a felony if the record amendment leads to substantial changes, again my case is federal but most states and Medicare have a judicial review component for contested amendments to be aware of and stiff penalties for noncompliance with those patient record rights.
Jeff,
Now that I am a senior and I do visit physicians for various reasons, I always get a copy of my medical records. I am so glad that I have done so. These are all fine physicians. No question about it. But, I do find omissions, and errors and oversights. My medical records are shared by the network that the docs belong to. The important areas are changed, but, it does take effort. I have found one of the offices that takes the time to correct all of the important pieces of the records and the other errors I just ignore as I bet nobody even pays attention to it. As a patient, I feel that I am only a widget in the current impersonal world of medicine. I am mindful that the world does not revolve around me, and the physicians whom I visit have their own problems as well as burnout and I do not add to their grief.
On the other hand, I have consulted a physician and a surgeon who were my clients in the past. In those offices, I am literally treated as a rock star by their staff. They spend plenty of time with me and their PEs and documentation are perfect.
Richard Willner
The Center for Peer Review Justice
Seems like a trivial matter.
Chart entry:
“Ms. Smith has requested that I amend her chart as follows: loren ipsum etc.”
And that’s it. You haven’t agreed or disagreed with the amendment(s), but you’ve noted the amendment request and attributed it.
If you agree with the request, it would be gracious to point out that Ms. Smith made you aware of something that had not previously occurred to you and that you do agree. If you don’t, it’s not obvious that you have to go on record, but you might want to do so.
Why is this a bi deal?
Sometimes cringe worthy comments are fun to read: Years ago I examined a woman of about 46 who had multiple, non-specific lower extremity complaints.
She also had some structural, orthopedic issues for which I treated her with orthotics and physiotherapy. I discussed the “possibility” of a gastroc recession because she was walking up on her toes.
My point is that about a year later she wrote me, (not asking to change her chart) but to inform me I missed her SLE diagnosis.
She had no skin lesions. SLE is a grab bag diagnosis with lots of varying symptoms.
I was glad she wrote me, but in all fairness to myself, I am not a rheumatologist. My consciousness raising would have to include visible skin lesions to get my clinical attention. I didn’t change her chart.
In order to do that I would probably have to see laboratory studies verifying her diagnosis.
Michael M. Rosenblatt, DPM