An accurate health record is fundamental to safe and continuous patient care. Errors within these documents, while uncommon, can lead to serious consequences, including incorrect treatment plans, misplaced diagnoses, and inaccurate billing. Because these records are used to make critical decisions about a person’s health, maintaining their integrity is a shared responsibility between the patient and the healthcare provider. Federal regulations grant patients the ability to seek a formal correction when they find information that is wrong or incomplete. This process ensures the patient’s history remains a reliable source of information for all involved in their care.
Understanding the Right to Amend Medical Records
Patients possess a federal right to request amendments to their medical information under the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule. This right applies to information held in the “designated record set,” which includes medical, billing, and other records used by a provider to make decisions about the individual. The goal of this provision is to correct information that is factually inaccurate or incomplete, such as a wrong birth date, an incorrect medication listed, or a mistaken diagnosis.
It is important to understand that this right is for correcting factual errors, not for challenging a provider’s professional judgment or opinion. For instance, a patient can generally correct a misspelling of a condition, but they cannot force a provider to remove a diagnosis they disagree with if the provider believes it is accurate based on their assessment. The right to amend is a request for a change, not a guarantee that the provider must alter the record. If the provider determines the information is accurate and complete, they can deny the request.
Steps for Submitting a Correction Request
The process for seeking a record correction begins with a formal, written submission to the healthcare entity. This written step is mandatory because it creates a clear, legal paper trail for the request and the provider’s subsequent response. The request should be directed to the facility’s Privacy Officer, Medical Records Department, or Health Information Management (HIM) department.
The written request must be highly specific to be effective, clearly identifying the patient with their full name and date of birth. It needs to state precisely which part of the record is incorrect, including the document name, the date of service, and the exact language or entry containing the error. The patient must then explain why the information is inaccurate or incomplete and state the exact correction or new information that should be added.
The request should include any supporting evidence that validates the proposed change, such as corrected lab results, notes from another physician, or discharge summaries. Many providers offer a specific form for amendment requests, which is the easiest way to ensure all required information is included. Patients should make a copy of the completed request and all supporting documents before submitting it.
How Providers Manage and Document Corrections
Once a provider receives a request, they are legally required to review and respond within a set timeframe. The provider must act on the request no later than 60 days after receiving it. If more time is needed to investigate, they can take a one-time extension of up to 30 additional days, provided they inform the patient in writing before the initial 60-day deadline expires.
A fundamental rule of medical record integrity is that the original information can never be deleted or erased. If the request is approved, the provider corrects the record by appending a formal amendment or addendum to the original entry. This correction is linked to the initial, incorrect information, ensuring the historical context is preserved. The provider must inform the patient in writing of the acceptance and then take reasonable steps to notify any relevant third parties, such as other providers or insurers, that previously received the incorrect information.
Recourse When a Correction Request is Denied
A denial of a correction request does not mean the patient’s options have been exhausted. If a provider refuses to make the amendment, they must send the patient a written Denial Notice in plain language. This notice must explain the specific reason for the denial and clearly inform the patient of their right to submit a Statement of Disagreement.
The Statement of Disagreement is a written document prepared by the patient, explaining why they disagree with the provider’s refusal. The provider must append this statement to the disputed portion of the medical record, ensuring that any future user sees the original entry, the denial, and the patient’s perspective. If the patient chooses not to submit a disagreement statement, they can still request that the original amendment request and the provider’s denial be included with any future disclosure. The final escalation path is to file a formal complaint with the U.S. Department of Health and Human Services’ Office for Civil Rights (OCR), which enforces the HIPAA Privacy Rule.