Mutual Matters

Accessing and Amending Medical Records

Posted by Bill Kanich, MD on Mar 9, 2017 3:27:31 PM

 MMIC_physician_computer.jpgCase Study #1

During an exam, Mr. Smith admits to his doctor that he used alcohol heavily in the past. The doctor notes this in the patient’s progress note. Subsequently, Mr. Smith applies for life insurance and learns that he is denied on the basis of the doctor’s note. Mr. Smith is upset and contacts his doctor to request an amendment of his medical record.

Case Study #2

Divorced parents are fighting over the custody of their two-year-old son. The mom calls the child’s provider and asks that information be added to her son’s medical record regarding a recent injury. She suggests that the injury could be the result of the father’s neglect.

Requests for Medical Records

MagMutual receives frequent calls about patients requesting redaction or amendment of their medical records. In the era of open access, patients now have the ability to request documentation of their visits with medical providers. Workers’ compensation, divorce and custody controversies, life or disability insurance application reviews, and ongoing legal proceedings all periodically lead to these types of requests. In each situation, sensitive information and potentially adverse comments in the record may result in unfavorable consequences for the patient.

Under HIPAA, patients have the right to review, (free of charge), and receive a copy, (for a fee), of their medical and billing records and any other records that are used to make decisions about a patient. Failure to comply with HIPAA’s access requirements is one of the top five most common violations of HIPAA.

A partial list of the most common records that a provider is not required to produce, (i.e. patients do not have a right of access), includes:

  • Quality assurance or professional review materials
  • Psychotherapy notes (personal notes of the therapist pertaining to counseling sessions; medications, dates of visits, billing information and other parts of the records are still subject to the right of access)
  • Information compiled in anticipation of a civil, administrative, or criminal action
  • A medical record which, if released, would likely cause harm to the patient or another person (in the professional judgment of the provider)
  • Research study records, but only if the patient agreed during the consent process and only while the clinical trial is in progress (patients must be informed that their right to access will be reinstated following the conclusion of the clinical trial)
  • Information obtained from someone other than a healthcare provider, such as a family member or close friend, under a promise of confidentiality

A common myth is that you cannot provide copies of another provider’s records that are contained in your records. This is not true. HIPAA FAQ’s for Professionals specifically states that a provider can produce such records and, in fact, it may be a violation of the right of access if you do not do so when requested by the patient.

A provider may require a patient to submit any request for access to records in writing, but only if the patient has been informed of this requirement, usually in the Notice of Privacy Practices. We recommend that providers have a requirement for a written request for access and that the request is signed and dated by the patient.

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Topics: Healthcare Industry, Practice Management