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Requests to Amend a Medical Record

As the first medical professional liability insurer to establish a patient safety department, The Doctors Company remains the leader in developing innovative tools that can help you reduce risk and keep your patients safe.

Patients have the right to request an amendment to their medical record. Physicians have the right to determine if the change will be made. The medical record should contain both the patient’s request and the physician’s response.

When a patient requests any kind of amendment to his or her medical record, follow these guidelines to help ensure clear documentation:
  • The patient’s request must be in writing and he or she must sign and date it.
  • The request must be directed to the originator of the portion of the record that the patient wants to amend.
  • The request must state which portion of the record the patient wants amended and how he or she wants it to be amended.
  • The patient’s request is then filed in the record with the pertinent entry.


Example 1

During an executive physical examination, a physician 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 physician incorrectly documents “ETOH: 5/day.” Subsequent health care providers who have received copies of this physical examination reference the patient’s “daily” alcohol intake. The patient eventually identifies the source of the confusion and requests an amendment to the medical record.

Example 2
A patient returning for follow up of her back strain due to gardening now insists that the original injury occurred at work and wants the prior visit note changed.
 

 
The provider, who may agree, partially agree, or disagree with the patient’s request, should take the following steps:
  • He or she indicates that “per the patient’s request, the record is amended as follows” and makes any appropriate changes or writes “I disagree with the patient’s request and the record will not be amended.”
  • The provider then signs and dates the response and places it with the patient’s request in the medical record with the pertinent entry.
  • The provider must make reasonable efforts to inform other individuals who received the original medical record and provide them with the amendment within a reasonable time, especially if the amendment provides information that may be detrimental to the patient.
  • The provider must act on the patient’s request for an amendment no later than 60 days after receipt of the request.

The record should clearly display in writing any efforts by the patient to amend the record and the provider’s response to the patient’s request. This documentation then becomes part of the patient’s medical record.

 

By Susan L. Marr, MSA, CPHRM, Patient Safety/Risk Management Account Executive, Southeast Regional Office, The Doctors Company.


 

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 health care provider in light of all circumstances prevailing in the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

J8039P 7/11


FIRST IN PATIENT SAFETY   |    www.thedoctors.com/patientsafety

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