Keeping Your Medical Records Accurate

By Lisa Zamosky

One of the more common types of questions I receive from readers has to do with medical records. Most commonly, people want to know either how to get a hold of their record or how to get rid of information that is wrong.  I’ve discussed before on this blog the process for gaining access to your medical record.

Today, I’m addressing a question I recently received from a reader about how to remove medical information from her records that she says is inaccurate.  Her doctor has diagnosed her with an illness she claims she does not have. How can she remedy this situation, she wants to know.

Dealing with Bad Information

When it comes to treatment information and medical diagnoses contained in a medical record, unfortunately, you can’t remove it. The reason for this is because medical records are legal documents that provide a rationale for the care you received. Removing information entirely means your record is not complete, which can have implications for future treatment. This also raises a host of medical liability issues for your doctor.

The fact is that just because you don’t agree with your doctor’s diagnosis, or don’t like what he or she has included in your record, doesn’t mean the information is wrong. It’s actually in your best interest that other physicians subsequently treating you see what your previous doctor had to say.

However, there are no doubt incidences in which the doctor has made an error and it’s important for a host of reasons that a correction is made.

Your Rights to Amend Your Record

The federal Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule entitles you to request an amendment to any information within your medical record that you think is wrong or incomplete. This includes information as mundane as your address or other demographic information, as well as content about a diagnosis or treatment.

To start, ask your health care provider about his or her particular process for requesting a medical record amendment. Once you make your request in writing, providers have a 60-day window to respond to your request and let you know whether or not they agree to make the change.

If your request to amend the medical information contained in your record is denied, you still have the right to have your version of the facts heard. Let the provider know that you want a statement of your views added to your record so that anyone who reads it going forward will also see that you’ve disputed the information. By law, your doctor must comply with this request.

In addition, you have the right by law to require your doctor to send the amended information to another health care provider.

If you have trouble making headway you can file a complaint with your state medical board.

You can also file a complaint with the Department of Health and Human Services’ Office for Civil Rights, which enforces the HIPAA Privacy Rule.

Have you tried to amend information in your medical record? Share your experience here.