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Under the HIPAA Privacy Rule, covered entities must honor certain patient requests to amend protected health information (PHI). Generally, a patient has the right to amend PHI or a record about the individual in a designated record set, for as long as the PHI is in a designated record set.
Changing a medical record to correct an error is anything but an easy process. Under federal HIPAA rules, patients have the right to request that doctors fix errors, but the provider has up to 60 days to respond, and can ask for a 30-day extension. The provider also can refuse, but must specify the reason in writing.
Under the Privacy Act, individuals have the right to request amendments of their records contained in a system of records.
Any corrected record submitted must make clear the specific change made, the date of the change and the identity of the person making that entry. Note that only the attending providerthat is, the provider who saw the patient and documented the initial note for the visit in questionmay amend the medical record.
An individual has the right to have a covered entity amend protected health information or a record about the individual in a designated record set for as long as the protected health information is maintained in the designated record set. (iv) Is accurate and complete. (1) Individual's request for amendment.
No. A patient's record should be complete and accurate to ensure they receive appropriate care. Patients can question the content of their records, but not on the basis that it is upsetting or that they disagree with it.
As long as your organization maintains a patient's information, the patient has the right to request that you make changes to (or amend) their information in a designated record set. Your organization is responsible for responding to the amendment request.
Reasons for Denial.The provider who received the amendment request had not created the original record. The record was created at another office. There is an exception if the creator is no longer available and the mistake in the record is apparent.
Proper Error Correction ProcedureDraw line through entry (thin pen line). Make sure that the inaccurate information is still legible.Initial and date the entry.State the reason for the error (i.e. in the margin or above the note if room).Document the correct information.
The covered entity may deny the request if it determines that the PHI or record that is the subject of the request: Was not created by the covered entity (unless the originator is no longer available to act on the request; 45 CFR §164.526 (a)(2)(i)