Patient requested I amend their medical record. Now what?

Provided by:  Jennifer Kirschenbaum, Esq.

September 20, 2022

Question:

Hi Jennifer,

A patient requested an amendment to their medical record.  Now what? 

Thanks, Dr. N

Answer:
 

Under the HIPAA Privacy Rule, patients may request amendments to their medical records. Providers may require the individual making the request to do so in writing and include a reason for the request. This will all become part of the medical record regardless of whether the provider actually amends the record. The Provider has 60 days to act on the request and if they cannot, they are allowed to extend the time period 30 days by providing the requestor with a written explanation of why.

https://www.hhs.gov/sites/default/files/ocr/privacy/hipaa/understanding/special/healthit/correction.pdf

You have broad discretion to deny the request, but, after you deny, the patient must have an opportunity to protest in writing.  HIPAA is fairly detailed about documentation and keeping the patient, or any other authorized recipient of the health record, informed of any accepted changes.    
https://www.hhs.gov/sites/default/files/ocr/privacy/hipaa/understanding/special/healthit/correction.pdf

You can reach out to us directly should you require assistance or more guidance on an amendment request, or with any issues handling a disruptive or combative patient.