Requests to Amend a Medical or Dental Record

Under the HIPAA Privacy Rule, patients have the right to request amendments to their healthcare records. Practitioners have the right to determine if the changes will be made. In these situations, document the record with both the patient’s request and the practitioner’s response. Consider the following scenarios and points outlined below:

Scenario 1

During an executive physical examination, a practitioner 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 practitioner incorrectly documents “ETOH: 5/day.” Subsequent healthcare practitioners 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 2

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.

Documenting Patient Requests

When you receive a patient request for any kind of amendment to a healthcare record, these strategies can help ensure clear documentation:

• The patient’s request must be in writing and must be signed and dated.
• Notify the patient that the request will become part of the permanent record.
• The request must be directed to the practitioner 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 and why it should be amended.
• The patient’s request is then filed in the record with the pertinent entry.
• The patient’s request for change and the practitioner’s written response become part of the permanent record.

Practitioner Response

Practitioners have the right to determine whether a requested amendment will be made. Take the following steps if you agree (or partially agree) with the patient’s request:

• Prepare and send a written response to the patient within 60 days of receipt of the original request. Sign and date the response.
• Indicate on the patient’s record that “per the patient’s request, the record is amended as follows,” and make any appropriate changes.
• Place a copy of the patient’s request and the written response with the pertinent entry in the patient’s record.
• Make a reasonable and timely effort to inform other individuals who received the original record and provide them with the amendment. This is especially important if relying on the original information could be detrimental to the patient.

Follow these steps if you disagree with the patient’s request:

• Prepare and send a written response to the patient within 60 days of receipt of the original request.
• Use plain language (rather than technical medical terms) that the patient will understand.
• Place the response in the patient’s permanent record with the request, and include the following information:
  
  • The reason for the denial. Common reasons to deny a patient’s request include that the practitioner who received the request did not create the record entry or that the patient record is accurate as-is.
  • A statement advising that the patient may submit a written reply disagreeing with the denial.
  • A statement telling the patient how to submit a reply to the practitioner or clinic.
  • A statement outlining that, regardless of whether the patient wishes to reply to the denial, copies of the original request and the practitioner’s denial will become part of the patient record and be included in responses to future inquiries regarding the patient’s healthcare information.
  • Notice to the patient regarding how to make a complaint to the healthcare practitioner or a HIPAA complaint to the Secretary of the U.S. Department of Health and Human Services, Office for Civil Rights either online or by telephone at (800) 368-1019.

Providing patients with a preprinted amendment request form can facilitate the process. 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 Patient Safety and Risk Management at (800) 421-2368 or by email.