Requests to Amend a Medical Record
A patient has the right to request an amendment to his or her medical record. A physician has 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 provider who originated the portion of the record the patient wants to amend.
- The request must state which portion of the record the patient wants to amend and specify how it should be amended.
- The patient’s request is then filed in the record with the pertinent entry.
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 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.
A 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.
A physician—who agrees or partially agrees with the patient’s request—should take the following steps:
- Indicate on the medical record that “Per the patient’s request, the record is amended as follows” and make any appropriate changes.
- Sign and date a response addressed to the patient and place a copy of it with the patient’s request in the medical record with the pertinent entry.
- Make a reasonable effort 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.
A provider who denies a patient’s request must respond to the patient in writing in a timely manner using plain language (rather than technical medical terms). The response should be placed in the medical record with the request and should include the following:
- The reason for the denial.
- A statement advising the patient that he or she may submit a written reply disagreeing with the denial.
- Information telling the patient how to submit a reply to the physician or clinic.
Written denials by a provider must also include statements with the following information:
- If the patient does not want to submit a reply to the denial, he or she may, instead, ask that copies of his or her original request and the physician’s denial be included in responses to future inquiries regarding the patient’s medical information.
- Notice to the patient regarding how to make a complaint to the provider or to the Secretary of the Department of Health and Human Services.
By Susan L. Marr, MSA, CPHRM, Senior Patient Safety Risk Manager, and Richard Cahill, JD, Vice President and Associate General Counsel.
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 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.