An Electronic Health Record (EHR) is a digital version of a patient’s medical chart, containing history from one or more providers. This record includes diagnoses, medications, lab results, and physician notes. The accuracy of this digital file is important because treatment decisions, prescriptions, and patient safety protocols rely on the information it contains. Correcting inaccuracies in the EHR is necessary to ensure appropriate and safe healthcare.
Legal Basis for Patient Record Changes
The ability for a patient to request changes to their health information is a right established by federal law under the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule. This Right of Amendment allows individuals to seek changes to their protected health information (PHI) if they believe the information is inaccurate or incomplete.
This right applies only to records within the “designated record set,” which includes medical and billing records used by the provider to make decisions about the patient. When requesting an amendment, the original, incorrect information will not be deleted but rather supplemented with the correction.
Filing the Formal Request for Correction
Before filing, determine the location and nature of the inaccuracy within your record, such as a wrong date of birth, an incorrect diagnosis, or a missing allergy. Pinpointing the exact entry that requires amendment is necessary for a successful request.
To begin the formal process, submit a written request to the healthcare entity, such as the hospital or clinic. Direct this request to a specific department, often the Health Information Management (HIM) office or the Privacy Officer. Using the provider’s specific amendment request form is recommended, as this ensures all necessary details are included.
The written request must clearly identify the PHI you are seeking to amend and state why the information is incorrect or incomplete. Provide a concise explanation for the change and include any supporting documentation, such as a second opinion report or lab result. You must also specify the exact change desired and where the amendment should be appended in the record.
Provider Obligations and Timelines
Once the healthcare provider receives your written request for amendment, they are obligated to act on it within a specific federal timeline. The provider must make a determination on your request no later than 60 days after receiving it. If the provider is unable to process the request within this initial period, they may extend the deadline by an additional 30 days.
To use this extension, the provider must notify you in writing before the initial 60-day deadline expires, explaining the reason for the delay and stating the date by which they will complete their action. If the provider accepts your request, they must make the appropriate amendment by adding the correction to the designated record set and ensuring it is linked to the disputed information. The provider is then required to notify you in writing that the amendment has been made.
If the request is granted, the provider must also make reasonable efforts to inform any other persons or entities, such as other healthcare providers or insurers, that the patient identified as having received the original, incorrect information. Conversely, if the provider denies the amendment, they must provide you with a written denial. This denial must be in plain language and clearly state the basis for the refusal.
Appealing a Refusal
If the healthcare provider denies your request for correction, you have several avenues for recourse. The written denial must inform you of your right to submit a Statement of Disagreement with the provider’s decision. This statement allows you to explain why you believe the information is inaccurate or incomplete, and the provider must append this document to the disputed record.
The provider has the option to prepare a written rebuttal to your Statement of Disagreement, and if they do, they must provide you with a copy. The provider is required to include your request for amendment, the denial, and any subsequent disagreement or rebuttal with any future disclosure of the disputed health information.
The denial notice must also include a description of how you can file a complaint with the provider’s internal complaint procedures. You maintain the right to file a formal complaint with the U.S. Department of Health and Human Services (HHS) Office for Civil Rights (OCR). The OCR enforces the HIPAA Privacy Rule and investigates violations.