Correcting Errors in Your Medical Records

Mistakes can affect your health care and outcomes

Nurse checking medical records
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By law, you have the right to correct errors in your medical records. The Health Insurance Portability and Accountability Act (HIPPA) ensures that your medical records are private. Another important part of this law allows you to request amendments to your medical record if you find errors.

This process for making this type of correction can be as simple as just letting your doctor know that something was recorded incorrectly so your doctor can change it. But sometimes corrections aren't so simple, and you need to familiarize yourself with the rules for "Amendment of protected health information" so that you can get the corrections taken care of.

Reviewing Your Records

While many patients are not interested in looking at their own medical records, it is a good idea to do do. Some healthcare systems will provide you with a patient portal that provides easy access to all of your medical records within that system. Even if you don't have that type of access, you are entitled to look at your own medical records and obtain copies. Sometimes there is a cost for getting copies of your records.

Once you have your medical records, you can review them. If you see any inaccuracies, you can determine whether they are important and require an amendment.

Types of errors can include:

  • Some typographical spelling errors may or may not require correction. For example, if mesenteric is incorrectly spelled "mesentiric," you might not go through the trouble of having it corrected because there won't be any impact on your health or medical care.
  • Errors in the spelling of your name do require correction because this can prevent your records from being shared properly among different providers, and it can affect payment for services.
  • If your phone number or address is incorrect or outdated, you'll want to make sure it gets corrected immediately. Failure to do so will result in the wrong information being copied into future medical records or an inability for your medical team to contact you if needed.
  • Any inaccurate information about your symptoms, diagnosis, or treatment should be corrected. For example, if your record says that you have temporal tumor instead of a testicular tumor, this is completely different and requires correction.
  • If the record says your appointment was at 2 p.m., but you never saw the doctor until 3:30 p.m., that may not have any bearing on your future health or billing information needs, and it isn't worth correcting.

    Overall, you have to make your own judgment about which parts of your medical record need to be corrected if you find errors. If you are on the fence, it is better to correct something than to leave it incorrect.

    Making Your Request

    Contact the hospital or your payer to ask if they have a form they require for making amendments to your medical records. If so, ask them to email, fax, or mail a copy to you.

    Sending in your request

    Be clear, concise and write the correction exactly as you think it should be noted. The idea is to make it very easy for your provider's office amend your records.

    Make a copy of the page(s) where the error(s) occur. If it's a simple correction, then you can strike one line through the incorrect information and handwrite the correction. By doing it this way, the person in the provider's office will be able to find the problem and make the correction easily. If they sent you a form to fill out, you can staple the copy to the form.

    If the correction is complicated, you may need to write a letter outlining what you think it is wrong and what the correction is. If you do write a letter, make sure you include some basics, such as your name and the date of service of your letter, then staple your letter to the copy of the page that contains the error.

    Your Provider's Responsibility

    The provider or facility must act on your request within 60 days but they may request an extension of up to 30 additional days if they provide a reason to you in writing. Your provider is required to inform you that they have accepted or denied your request for an amendment in a timely manner. If you requested that other providers, business associates, or others involved in your care are also informed of the amendment, your provider must inform them as well.

    Your providers are not required to make the change you request. If they deny your request, they must notify you of their decision in writing and keep a record of your request and their denial in your medical records.

    There are a number of reasons for a denial. Some patients request that information about drug use, sexually transmitted diseases, violent outbursts, or other sensitive topics be removed. However, most providers will refuse to remove this information because it has an effect on your health and medical treatment.

    A Word From Verywell

    Your medical record may appear complicated at first, especially if you aren't used to looking at medical records. But once you start to read it, you will begin to recognize the important features. If you have any concerns, discuss the matter with your doctor's office–the vast majority of the time, you will get a speedy correction. If that isn't the case, you will need to follow the proper procedures to get things corrected, or at least considered.

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