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:
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:
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:
Written denials by a provider must also include statements with the following information:
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.