I Don’t Want That in My Record

When patients request corrections of their medical records, practices need to respond to these requests.

Patients are reading their medical records and seeing errors and things they don’t like. The federal Open Notes Rule, or Information Blocking Rule, has made it easier for patients to read their electronic medical record or they may simply have requested access to their record under the Health Insurance Portability and Accountability Act (“HIPAA”) Privacy Rule. As a result, medical practice staff are managing more patient-initiated requests to delete or correct those things.

What’s Really Going On?

Sometimes patients’ and their representatives’ requests are valid. For example, a physician assistant documented, “Breasts appear normal, no palpable lumps,” about a patient who had undergone a left radical mastectomy and removal of the pectoral muscle and axillary lymph nodes. Sometimes requests are denied, usually because the information is accurate and clinically relevant.

Examples of Requests to Amend the Medical Record1

Excerpt from medical record Patient amendment request
“Past medical history includes Graves disease with prior ablation and dyslipidemia”

“I never had ablation and dyslipidemia. Take this out."

“Secondary diagnosis of depression.” “My psychiatrist treats my depression. It doesn’t need to be in my PCP’s record.”
“Father has AIDS.” “This doesn’t need to be in my daughter’s chart. She never sees him.”

Patient Rights and Clinician Duties

Regardless of the validity of the request, patients enjoy certain rights and clinicians have specific duties under the HIPAA Privacy Rule.2

    • Patients have a right to access3 their medical and health information in designated record sets4 maintained by their physicians and advanced health care professionals (collectively “Clinicians”).
An analysis of over 20,000 closed claims filed nationwide showed that communication was a factor in 30% of the cases.4 (20)
    • Patients have a right to request that the clinician or practice amend5 their protected health information (“PHI”) in designated record sets.

    • Clinicians and their practices must:
      • permit patients or their representatives to request an amendment to PHI6 and
      • act on the request within 60 days of receiving7 it.
    • If clinicians or practices cannot act on the request 60 days after receipt, they must give, in writing, the patient or representative the reason for the delay and the date by which action on the request will be completed.8 Action on the request must be completed within 90 days of receipt of the request.

Acting on Requests

Clinicians and their practices don’t have to make requested changes, but they do have to respond to the requests. A formal process for managing requests to amend PHI will help clinicians and practices honor their patients’ rights and ensure their compliance with the HIPAA Privacy Rule.

Don't have a process? Here are two complimentary tools to get you started.

Checklist for Acting on Requests To Amend Medical Records

Managing Requests to Amend PHI Process Template and Example Denial Letter 

1 See Hanauer, D.A., Preib, R., Zheng, K., Choic, S.W. (2014). Patient-initiated electronic health record amendment requests. J Am Med Inform Assoc, 21:992-1000. for more examples.

2 State laws may also apply to the right of access.

3 Patients do not have the right to access two categories of information: 1) psychotherapy notes (personal notes by physician or other mental health care professional documenting or analyzing a counseling session) that are maintained separate from the rest of the patient’s medical record and 2) information compiled in reasonable anticipation of, or for use in, a civil, criminal, or administrative action or proceeding. 45 CFR § 164.524(a)(1)(i)-(ii).

4 A “designated record set” is a group of records maintained by or for a covered entity and is comprised of medical records; billing and payment records; health insurance information; clinical laboratory results; medical images, such as x-rays; wellness and disease management program files; clinical case notes; and other information used to make decisions about a particular patient or any patients. 45 CFR § 164.501.

5 The right of amendment is stated in a federal regulation at 45 CFR § 164.526(a)(1).

6 The clinician’s or medical practice’s duty to permit amendment requests is explained at 45 CFR § 164.526(b)(1).

7 See 45 CFR § 164.526(b)(2) for details about the 60-day deadline.

8 Id. at § 164.526(b)(2)(ii)

The content of this publication or presentation is intended for educational purposes only; is not an official position statement of Mutual Insurance Company of Arizona (MICA); and should not be considered or relied upon as professional, medical, or legal advice or as a substitute for your professional judgment. Consult your attorney about your individual situation and the applicable laws. The authors, presenters, and editors made a reasonable effort to ensure the accuracy of the information at the time of publication or presentation but do not warrant or guarantee accuracy, completeness, or currency of such information. As medical and legal information is constantly changing and evolving, check for updated information and consult your attorney before making decisions.

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