When Patients Want You to Change Medical Records
Have you had a patient request to change their medical record? This week we cover what steps should be taken when a patient disagrees with an entry in your medical records. Watch the video to learn more!
Link for today’s video:
When one of our members call this week, who had an interesting request from a patient, that they change their medical record and change one of the indications that was included in their documentation, the first thing that you have to know is the patient does have a right to make a request that you review either to change, to correct, or to modify to make something more clear. Now, in those cases, if you examine the medical record after a patient’s made this request, and you make the determination that maybe there was a mistake, or you had mistyped, or made another small error or whatever in or error in the documentation, then at that stage, you want to make sure that you do make an amendment right. So you don’t want to just change the medical record, we don’t do that, right? So you would make an amendment to the medical record to correct the error that you would have included in there, just to ensure that it is appropriately reflecting the patient’s condition, and, and service or whatever it’s rendered.
Now, what happens if you review that you go, well, actually, the medical record is correct, that is actually a factual diagnosis, or that is a factual piece of information. And that is exactly what I did in service. And I’m not willing to change the medical record, I’m not willing to make an amendment to the medical record. But instead, I disagree with a patient, and after discussion with the patient, the patient still disagrees, in this case, what you would do is you would just tell the patient, that they actually have the right, to provide you with a statement of disagreement, that you would then make a permanent part of the patient’s medical record. And so that is an important allowance for the patient. So the patient can issue a statement of disagreement. And they would just issue that statement, and give it to you. And you would make that a part of the medical record that would be retained, as long as you keep your medical records, according to both state and federal law. And we’ve got a lot of videos on that, to hopefully clarify that for you.
But what happens if it’s something that’s a bit softer? And you’re like, wow, what do I do here and, and, for example, if the patient doesn’t like the stigma attached to the word obese, and it’s in the medical record, however, you have calculated the BMI and they meet the medical definition of obese, and you you do believe that that is a critical part of the diagnosis, that it does make a difference in your overall diagnosis and the service and the treatments that you’re providing that patient and provides useful, important information for their medical history, all of those things being true at that stage, what you could do is again, in this particular case, you can make sure that the patient understands that this is a medical diagnosis and, and nothing related to a public stigma. And also then just informed them that they have the right to issue a statement of disagreement that you would then make a part of your medical record.
In these cases, hopefully, you can work it out with the patient and then they begin to understand or you make the appropriate amendments to the medical record to correct it if there’s a mistake, but that’s the process that you would go through. Hopefully, this helps you out and we’ll catch you next week.