The Accuracy Factor – an Important Consideration when Amending Medical Records

by | Published on Aug 29, 2016 | Medical Record Review

Providers of medical record review for attorneys know that the trial lawyer’s case relies a great deal on the accuracy of the medical records involved. However, medical records can become unreliable especially when amendments to the records are not made appropriately. This is a major concern and reviewers working with attorneys have the very important responsibility to ensure that the medical records are accurate.

Sometimes, patients may request an amendment to be made their records. Patients have the right to request such an amendment. Any request for medical records and amendment to the medical documentation must be made in compliance with federal law. Here are some important facts in this regard.

  • The request must be made in written form, and must be signed and dated.
  • The request should be made to the healthcare provider who created the particular record.
  • The request must clearly indicate the specific part of the record where the amendment is to be made, and specify how it should be amended.
  • A healthcare provider has the right to decide whether to amend the medical record or not.
  • Upon receiving the request for amendment, the provider must act on the request within 60 days. Otherwise, he/she will have to provide written notice and the reason for the delay.

Typically, a provider may agree to amend a record that is inaccurate or incomplete. If any amendment is made in the record, the provider should note that “Per the patient’s request, the record is amended as follows” and then make the necessary changes. Importantly, the amendment should be dated and signed. In addition, the provider who makes the amendment should try to provide the amendment to others who may have received the pre-amendment records.

What if a request for amendment is denied?

Providers who deny such a request must send a denial written in simple language, clearly mentioning the reason for the denial. He/she has to inform the patient of the right and procedure to submit a written statement stating the disagreement. In addition,

  • The provider has to inform the patient that he/she can instead request that copies of the amendment request and the provider’s denial be included in response to future inquiries for medical records.
  • Inform how the patient can complain to the provider or to the secretary of the Department of Health and Human Services.

The patient can write a statement of disagreement and also clearly specify the basis for disagreement. A provider can limit the statement’s length and also prepare a written rebuttal. A copy of the rebuttal can be provided to the patient. All amendment related documents must be carefully maintained along with the medical records by the provider irrespective of whether the request to amend is accepted or denied.

Medical record review companies assisting injury attorneys with medical review services are thoroughly professional and can clearly identify tampering, misinformation, lack of information and errors in the medical records they analyze. As the medical record is the single most important evidence for healthcare providers in lawsuits, inquests and hearings, it is vital that the documentation therein is accurate. Prudent lawyers know the importance of carrying out a comprehensive investigation that involves careful medical records analysis. These healthcare documents are vital in social security disability, personal injury and workers’ compensation cases. To verify accuracy of the medical records, they would:

  • Request and review all relevant medical records.
  • Interact constantly with all treating physicians and other clinical staff.
  • Review the testimony given at depositions and hearings to ensure accuracy.

People themselves should take active interest in their health related matters ensure that their medical history is accurate. They should make sure that any new medical treatment is accurately recorded. They should be aware of the importance of the medical record as a legal document and how it is vital with regard to processes such as medical claims review and medical peer review. Accurate medical records are also the best defense for healthcare practitioners in the event of a medical malpractice case.

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