The accuracy of a healthcare record is foundational to safe and coordinated medical attention. Errors can range from simple clerical mistakes to significant clinical inaccuracies, such as a wrong diagnosis or an omitted drug allergy. Inaccurate records can lead providers to make clinical decisions based on misleading information, impacting patient safety and continuity of care. Furthermore, these records serve as the basis for insurance claims and legal documentation.
Understanding Your Right to Amend Records
Patients have the right to request changes to their health information to ensure its integrity. The legal framework mandates that healthcare providers permit a patient to submit a request to amend information contained within their designated record set, such as medical and billing records.
The right to request an amendment applies to information a patient believes is inaccurate or incomplete. Providers cannot erase information from the official health record, as the record must maintain a complete historical and legal audit trail. Instead, the correction process involves appending the requested amendment to the original entry, ensuring the former entry remains visible but is clearly noted as updated.
This mechanism allows for the correction of factual errors while preserving the context of the initial documentation. When an amendment is approved, the health information system must integrate the new, corrected data into the record.
Providers are legally required to comply with all reasonable requests for correction. This empowers the patient to actively participate in the management of their health information.
Steps for Submitting a Formal Correction Request
The correction process begins with a formal, written request submitted to the healthcare provider. Many providers offer a specific form, often obtained from the Medical Records Department or the Privacy Officer. If a form is unavailable, a clear letter can be used instead.
The written request must be highly specific, clearly identifying the part of the record that is incorrect or incomplete. Patients should include their full name, contact information, the date of service, and the name of the provider who created the entry. The request must specify the exact location of the error and articulate the precise reason for the requested change.
The request must clearly state the proposed correction or the wording of the missing information. This proposed language will be the amendment appended to the original record. Submitting the request via certified mail or a secure patient portal is advisable to ensure a verifiable record of delivery.
Provider Response Timelines and Appeal Options
Once a provider receives a formal request, they must act promptly. The mandated response period is no later than 60 days after the request is received. If the provider needs more time, they may extend the review period by a single additional 30 days, provided they inform the patient in writing of the reason for the delay.
The provider will either accept the request, make the amendment, and notify the patient in writing, or deny the request. If denied, the provider must issue a formal written notice explaining the grounds for the denial in plain language. Denial typically occurs if the information is deemed accurate and complete, or if the information was not originally created by that provider.
If the request is denied, the patient retains the right to submit a Statement of Disagreement. This brief, written document explains the patient’s perspective on why the record is incorrect. The provider must include this Statement of Disagreement in the medical record and attach it to any subsequent disclosures of the disputed information. Patients may also file a complaint with the provider’s compliance officer or the federal Office for Civil Rights if proper procedure was not followed.