Yolanda Sims, JD, MHA

Question

On occasion, patients dispute information in their medical records. What guidelines should we follow if their request to amend the record is denied? 

Answer

A patient typically requests an amendment when they believe the information in their medical records is incomplete or inaccurate. In general, an amendment is a correction a covered entity agrees to make to a patient’s medical record. An amendment doesn’t change the original medical record; rather, it is added to the record as a correction. Under certain circumstances, covered entities can deny a patient’s request for an amendment.

Under the HIPAA Privacy Rule, patients have the right to amend medical records as provided by 45 C.F.R. 164.562. Under this statute, the covered entity must act timely, usually within 60 days, to either correct the record as requested by the individual or to notify the individual their request is denied.

Request Denial in Writing

The denial of an amendment must be communicated in writing and should indicate one of the following reasons for the denial:

• The record is accurate and complete
• The record was not created by the organization or the provider in question
• The record is not a part of the designated record set
• The patient does not have the right to access this record

Statement of Disagreement

If the patient disagrees with the denial of the amendment request, they have a right to submit a statement of disagreement. In response to the statement of disagreement, a provider may submit a rebuttal statement.

Documentation

Following a denial, the covered entity must provide proper documentation of the dispute with any subsequent disclosures of the disputed information. For recordkeeping purposes, place a copy of the initial request, the denial of the request, the statement of disagreement, the provider’s rebuttal statement, and any supporting documents in the patient’s medical record.

For a complete review of the HIPAA amendment process, see 45 C.F.R. 164.526 for additional guidance.