What is the procedure to amend medical records?

Procedure to Amend Medical Records

To amend medical records, follow a structured process that includes patient request submission, provider review, documentation of the amendment decision, and appropriate notification to all parties involved. 1, 2

Patient-Initiated Amendment Process

• Patients have the right to request amendments to their medical records when they identify incorrect or incomplete information 3
• Amendment requests should be submitted in writing, specifying the information to be corrected and providing supporting documentation when available 2
• Patients typically identify errors when reviewing their medical records, with approximately 0.2% of patients who access their records submitting amendment requests 3
• The majority of amendment requests (77.8%) are made to rectify incorrect information in the medical record 3

Provider Review and Decision Process

• Upon receiving an amendment request, the healthcare provider must review the request and make a determination based on the accuracy and completeness of the information 1, 2
• The provider should evaluate whether the requested change is appropriate for maintaining accurate clinical documentation 2
• Approximately 49.7% of amendment requests are ultimately approved, while requests to remove valid information have a lower approval rate (27.8%) 3
• The healthcare provider must document their decision regarding the amendment request, including rationale for approval or denial 1

Documentation of Amendments

• When amendments are approved, they should be clearly documented in the medical record with appropriate metadata including author information, authentication details, timestamps, and document status 2
• Amendments should never replace the original documentation but should be added as supplementary information 1, 4
• The amended record should include:
  • The original documentation
  • The amendment with date and time
  • The identity of the person making the amendment
  • Clear indication that this is an amendment to the original record 1, 5

Notification Requirements

• The healthcare provider must notify the patient of the decision regarding their amendment request 2
• If the amendment is approved, the provider must inform all entities that previously received the information about the amendment 3
• If the amendment is denied, the provider must provide the patient with a written explanation for the denial 2
• Patients have the right to submit a statement of disagreement if their amendment request is denied 1

Electronic Health Record Considerations

• Electronic health records (EHRs) should support the amendment process through appropriate documentation tools 1, 2
• EHRs should maintain the integrity of the patient narrative while allowing for structured data capture when necessary 1
• The amendment process in EHRs should follow the "write once, reuse many times" principle, with appropriate tagging to identify the original source of information 1
• Auto-authentication of medical records without proper review raises serious concerns regarding accountability and accuracy 5

Best Practices for Amendment Management

• Healthcare organizations should establish clear policies and procedures for handling amendment requests 1
• Staff should be trained on the amendment process and the importance of maintaining accurate medical records 1
• The amendment process should be designed to support the primary purpose of clinical documentation: enhancing patient care and improving clinical outcomes 1
• Healthcare providers should avoid "copy/paste" of entire notes without editing, as this can propagate errors that may later require amendments 2

Legal Considerations

• Medical records serve as legal documents and providers have several legal duties, including maintaining adequate records and safeguarding their physical existence 6
• Tampering with medical records can be discovered through sophisticated techniques and may have serious legal consequences 6
• The legal medical record (LMR) is not necessarily synonymous with the electronic health record (EHR), and organizations must define what constitutes their LMR 4
• Healthcare providers should be aware of state and federal laws governing medical record amendments 5