Click here for the main story, "Open Notes Shines Light on Errors in Patient Medical Records."
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.
If the fix moves forward, the doctor can't alter the original note, but the patient has the right to have an amendment with his or her version of the facts placed in their electronic medical record (EMR).
Most EMR program modules do not let the patient edit or question something in an electronic note, although software entrepreneurs are working on solutions that will enable that feature.
"There's not a smooth process for doing that in today's EMRs. They didn't really build that into the certification criteria," said Deven McGraw, an attorney and chief regulatory officer for Ciitizen, a consumer health technology startup.
Then there's the question of who is responsible for actually making the fix and whether there even is a process. The doctor might refer the patient to the office staff or the doctor's nurse, who might refer the patient to the practice's health information or medical records office, which may send the patient back to the doctor.
It's also unclear whether any federal rules require the doctor to post the patient's requested amendment in the patient's portal so other providers can see the change. In one case relayed to MedPage Today, a doctor told a patient that he accepted the amendment but did not download it into the portal.
When asked to amend a chart note that incorrectly diagnosed this reporter with osteoporosis, the physician replied that it was inserted only so that Medicare would cover bloodwork for a vitamin D level, for which the patient would otherwise have to pay. "I was trying to save you money," the physician said.
That's not just wrong, it's potentially harmful, said Heather Gantzer, MD, immediate past chair of the American College of Physicians' Board of Regents.
If the patient came to the ED with acute back pain and compression fracture on a plane x-ray, and the ED team sees osteoporosis in the patient's history, a treating physician might say, "this happens" in people with osteoporosis, and initially discount any idea of something more serious, Gantzer said.
If the patient's record didn't indicate osteoporosis, she said, "maybe you are worked up with an MRI sooner rather than later, to be sure it's not a tumor."
Explore these tips on how to make sure your health record is accurate — it’s your right.
Providers need complete and accurate information to provide you with the right care. Once you get your health record (also known as a medical record), look it over to make sure that all of your health information is complete, correct, and up to date. This is important because you may have forgotten to tell your health care provider something or they may have forgotten to write it down. The staff in your provider’s office are busy people who make mistakes just like everyone else. Some examples of common errors:
- You may have forgotten to tell your provider about something — like a new medication or allergy
- Your provider might have misunderstood, incorrectly noted, or left out something — like information about your health history or your symptoms
- Your provider might have charged you for a test you didn’t have
If you don’t check your record, you won’t know these mistakes have been made, and they could impact your future health and treatment. Explore these tips on what kind of mistakes to look for - and what to do if you find one!
What kind of mistakes am I looking for?
You’re looking for mistakes or out-of-date information that will affect how your health care provider diagnoses and treats you, whether your provider can contact you, and how you’ll be billed. You can let typos go, but if a mistake can affect your health or your bank account, it should be fixed.
Check your personal information, including:
- Name, address, and phone number
- Health insurance plan’s name and phone number
- Identification numbers, like your patient identification number or social security number
- Emergency contact names, addresses, and phone numbers
Check your health information, including:
- Doctor’s appointment notes
- Health or medical history
- Signs of illness (called symptoms)
- Immunizations
- Health conditions (sometimes called diagnoses or problem lists)
- Allergies
- Medicines (what you take, how much, and when)
- Tests
- Surgeries and other procedures
Check your medical bills:
Make sure you’re only being charged for services you’ve received. You can do this by comparing the information in your health record with:
- The reports your health insurance plan sends you (often called Explanation of Benefits)
- The bills from your doctor or other health care providers
Frequently Asked Question
Some of my older records are missing — can I get them?
Yes, if they still exist. State laws determine how long a health care provider must keep your health records — and it varies from state to state. Some providers archive (store) older records offsite. If you haven’t been to your provider in more than 5 years, your records may have been put in storage — but you still have the right to get a copy.
If you think there’s a mistake in your health record, you have a right under the HIPAA Privacy Rule to ask your health care provider to fix it.
If you want to have a mistake fixed, follow these steps:
Contact your provider’s office and find out what their process is for updating or correcting your health record. They may ask you to write a letter or fill out a form. If they have a form, ask them to email, fax, or mail a copy to you.
For more information about how to contact your provider, see How do I get started?
If your provider has a form, and you want to fix a simple mistake, fill out the form and attach a copy of the health record page where you found the mistake.
If your provider doesn’t have a form or if the mistake is complex, you may want to write a letter describing the correction. Make sure you include:
- Your full name, address, and phone number
- Your doctor’s, nurse’s, or provider’s full name and address
- Date of service
- A short, specific, and clear explanation of what needs to be fixed and why
- A copy of the record page where you found the mistake
Make a complete copy of everything you’re sending to your provider for your own records.
Depending on your provider’s processes, you may be able to deliver your request different ways:
- Secure email through your patient portal
- Non-secure email (your personal email)
- Fax
- Mail (standard postal service)
- In person
Note: If you want to send your request by email, you’ll need to attach digital copies (PDF files) of the record page where you found the mistake and the request form. Messages you send through your patient portal are secure, which helps protect your privacy and personal information. But your personal email isn’t secure, which makes it easier for someone to view or steal your personal information.
Troubleshooting Tip
Find out who needs to fix the mistake
Make sure you address your request to the specific doctor or other provider who made the mistake. It will be their responsibility to fix it. Note: Your doctor or provider may have retired or changed practices. If this is the case, the clinic, office, or hospital can tell you who should take care of your request.
Frequently Asked Question
I make health care decisions for my child, a family member, or another adult — can I ask to fix something in their health record?
Yes. If you legally make health care decisions for someone else, the process is the same as fixing a mistake in your own record. Under the HIPAA Privacy Rule, a person who is legally authorized to make health care decisions for someone else is called a personal representative. Health care providers are not required to respond to requests from caregivers who are not personal representatives. If the person is someone other than your child, the provider may ask to see a copy of your medical power of attorney (or other legal paperwork showing your authority) before responding to your request. Get more information on personal representatives.
What happens after I request a correction?
Your health care provider has 60 days to respond to your request, unless they ask for an extension (extra time). Here’s what you can expect:
If your provider agrees there’s a mistake in your health record, they’ll update your record and send you a notice — either in your patient portal or via email or mail — that they’ve taken care of it.
If your provider does not agree with you, they’ll send you a denial notice that should include:
- The reason they’re not going to change the record. For example, they might say they believe your health record is correct and complete.
- Information about how to respond to their decision.
What do I do if my provider doesn’t agree with my request?
If your health care provider does not agree with you that there is a mistake in your health record, you can:
- Send them a formal letter in reply to their decision, stating clearly why you disagree. Their denial notice should include instructions on how to do that. If not, call their office. Your response will be attached to your health record.
- If you don’t want to reply to the denial notice, you can ask your provider to attach a copy of your original request and the denial notice to the affected page(s) of your health record.
- File a complaint with the Department of Health and Human Services if you think the reason the provider gives you for denying your request is wrong. Get more information on filing a complaint at HHS.gov.