Can individuals request to have an amendment made to their medical records?
The HIPAA Privacy Rule permits patients to request that PHI contained in their medical records, be amended. The right is not unlimited, however, and a covered entity may deny a request to amend PHI under several circumstances.
Show What is the HIPAA Privacy Rule Right to Amend PHI?Under the HIPAA Privacy Rule, covered entities must honor certain patient requests to amend protected health information (PHI). Generally, a patient has the right to amend PHI or a record about the individual in a designated record set, for as long as the PHI is in a designated record set. A “designated record set” is defined as a group of records maintained by or for a covered entity that comprises of:
A “record” in a designated set includes any item, collection, or grouping of information that includes PHI and is maintained, collected, used, or disseminated by or for a covered entity. Records include items such as medical records, lab results, and medical images (such as X-rays). When May a Covered Entity Deny a Request to Amend PHI?If a patient makes a PHI amendment request, the covered entity must grant the request unless a specific HIPAA Privacy Rule provision allows for denial of the request. Under the HIPAA Privacy Rule, a covered entity may deny a patient’s request to amend PHI, if the covered entity determines that the protected health information or record that is the subject of the request:
If the covered entity denies the requested amendment, in whole or in part, the covered entity must provide the patient with a timely, written denial, in plain language. The covered entity must inform the patient of its decision to deny the request within 60 days after the covered entity has received the request. The denial must contain the following information:
What is a Statement of Disagreement?If the covered entity denies all or part of a requested amendment, the covered entity must permit the individual to submit to the covered entity a written statement disagreeing with the denial of all or part of a requested amendment . The patient may state the basis of the disagreement in the written statement. The covered entity is permitted to reasonably limit the length of a statement of disagreement. If an individual submits a written statement, the covered entity is entitled to prepare a written rebuttal to the individual‘s statement of disagreement. The covered entity must provide a copy of the rebuttal to the patient who submitted the statement of disagreement. What are 3 things you should not add to a medical record?The following is a list of items you should not include in the medical entry:. Financial or health insurance information,. Subjective opinions,. Speculations,. Blame of others or self-doubt,. Legal information such as narratives provided to your professional liability carrier or correspondence with your defense attorney,. Who decides whether a medical record can be released?The physician should ask the patient to sign a written authorization to release this nontherapeutic information. The written permission should be dated, state to whom the information is to be released, which information may be passed on to that party, and when the permission to obtain information expires.
What is a chart amendment?A Medical Record Amendment is: A change, edit or update of medical record information requested by the patient when they feel the information documented is incorrect. If: Information in your medical record is out of date, such as: ➢ A medication you are no longer on or.
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