When you discover an error in your medical record you have a legal right to correct or amend them. The code of federal regulations (CFR) and the Health Insurance Portability and Accountability Act (HIPAA) afford you the right to request an amendment to medical records. The CFR and HIPAA are both legal documents so I’m going to do my best to break this down into understandable terms.
The Code of Federal Regulations, §164.526 states that 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.”
Let’s unpack that:
Oh, the Symbol “§” means “Sub-Section”. I had to look that up.
COVERED ENTITIES include health plans (insurers), healthcare clearinghouses (like billing services) or healthcare providers (like your doctors, clinics, hospitals). You can determine if someone or something is a covered entity by using the Center for Medicare and Medicaid Services (CMS) Guidance tool.
PROTECTED HEALTH INFORMATION (PHI): individually identifiable health information in any form, by any agent of a covered entity. This includes
- past, present and future physical or mental health information (that’s a lot of info)
- healthcare provided to an individual (tests/exams, test/exam results, procedures, etc)
- payments for healthcare provided
- That can be reasonably used to identify the individual (name, address, SSN, date of birth plus city, etc)
DESIGNATED RECORD SET is any group of records maintained by or for a covered entity and can include patient medical or billing records, enrollment, payments, claims, case or medical management, or any records that can be used to make decisions about you and yours.
RECORDS are any item/s, collection/s, or grouping/s of information that includes Protected Health Information and is utilized by a covered entity.
TO WHOM and HOW TO REQUEST AMENDMENTS/CORRECTIONS
Errors in your medical record will be there forever. Nothing can be erased because medical records are legal documents. However, you can request an amendment that addresses the error so the info reflected is accurate. You can do this verbally, but my advice is to do it in writing. Naturally, the covered entity to send the request to is the one who either generated or currently controls access to the designated record set in question.
Once received, a covered entity has 60 days to act upon your request to amend your medical record. The action they take could be
- Acceptance: Meaning the covered entity finds the record in question, agrees with your request and makes the amendment. They notify you plus any relevant others that need to be made aware of the amendment.
- Denial: Meaning the covered entity does not agree with your request. They must provide a written denial that includes the basis of the denial AND information about the individual’s right to submit a written statement disagreeing with the denial.
WHAT DO I SAY WHEN REQUESTING AN AMENDMENT TO MEDICAL RECORDS?
First you would point out the error in as much detail as possible then state clearly what the correct information is that you are asking to be amended.
Then you might add something like:
“I am making this request in accordance with The Code of Federal Regulations, §164.526 which states that 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.” This falls under the Health Insurance Portability and Accountability Act (HIPAA).
As the COVERED ENTITY of my DESIGNATED RECORD SET, and according to the CFR §164.526, you must act within 60 days to enact this amendment and to inform any entities that have recorded or utilized this error in my Protected Health Information.”
The point is twofold:
- Leave no room for misunderstanding of what you need
- Make sure they know that you know what your rights are
The law is on your side, but that doesn’t mean every covered entity knows that law or has done this before. You are making a formal, legal request and providing what guidance you can. You could even include a copy of the CFR §164.526 for their reference.
SO WHAT DOES AN AMENDMENT TO MEDICAL RECORDS LOOK LIKE?
ON PAPER RECORDS:
Let’s say, your blood pressure was accidentally recorded as “1200/700” on a report. That error can be addressed by making a line through it, adding and circling the correct information, dating and signing the change.
IN THE ELECTRONIC MEDICAL RECORD:
Electronic medical records (EMRs or EHRs) are harder to fix. However, the covered entity has to do the equivalent of what you do on Paper Records. It’s complicated but in the end, the original error remains in the record for legal reasons, but the corrected information is clearly present.
AVOIDING THIS PROBLEM IN THE FUTURE
My parents call me Jimmy. My wife and friends call me Jim. Some places I’m James. In my personal life that’s fine, but if my medical record sometimes said Jimmy/Jim/James it would cause problems. Here are some ways to avoid such errors:
- Always use your legal name. If your name changes, request a change to your record
- Demand access to your records. They are your records after all
- Review and organize your records. Make sure your data is correct. Consider using a secure form of maintaining your own records
Getting your medical records right isn’t convenient. However, it actually protects you against medical and billing errors. When healthcare isn’t working for you, your medical record is the cornerstone of every argument you can make for yourself. Make sure it is correct. It’s your right.
Jim Sliney Jr. is a Registered Medical Assistant and a Columbia University trained Writer/Editor. He creates education and advocacy materials for patient support groups. He has worked closely with several rare disease communities. Jim also coordinates the patient content for PatientsRising and collaborates with other writers to hone their craft. He’s an author and native New Yorker where he lives with his wife and all their cats. Connections: Twitter Quora Email