Medical records hold essential information about our past, lending to why it is so crucial our records are completely accurate. False information as seemingly mundane as medication can have a huge and negative impact on your future care. Patients have a responsibility to themselves to participate their medical care to prevent these errors, which includes correcting erroneous information in their medical records, to significantly reduce any chance of harm.
Request Copies of Your Records
Obtain a complete copy of the medical records you believe to have errors. You have a right under the Health Information Portability and Accessibility Act – commonly referred to as HIPAA – to request copies of and review your medical records whenever you desire. Contact the physician's office or hospital where you were treated, and ask them for a HIPAA authorization form so that you can request your medical records.
Fill Out a HIPPA Authorization
Fill out the HIPPA authorization, which must include your full name, date of birth and Social Security number. You must state the name of the physician, clinic or hospital that you are sending the request to. State what documents you are specifically requesting, or ask for everything pertaining to your treatment. Include the dates of service for which you are requesting records.
Prove Your Identity
Submit the completed form to the office. You can do so by mail or in person. You may also need to show photo identification, such as a driver's license, to prove your identity before the records are released. If you are sending the request by mail, ask if they will accept a copy of your driver's license to satisfy this requirement. You will also need to pay the copying costs. After paying, the physician has 30 days to supply you with a full copy of your medical records. In limited circumstances, a medical provider may deny your request. If this happens, you have the right to have the decision reviewed by a licensed health care professional who did not participate in the original decision to deny.
Check For Errors
Make a note of any false information your find in your medical records. When you do find an error, check for that same error in later records; there's a chance that if the error was recorded once, it was recorded again. Small errors, like misspellings and typographical errors or errors in dates and times, rarely need correcting, so you can disregard these.
Create a Spreadsheet
Start a typed document your full name, address, date of birth and Social Security number at the top. Underneath this, create a ledger with four columns and add Label the columns “Error,” “Correction” “Location,” and “Notes.” List your errors in chronological order of the records they were found on, from earliest to most recent. Fill in the false information in the first column, and next to it include the correction. Under “Location,” list the page title of record the error was found on, the page number, date and where on the page it was found. In the “Notes” section, you can explain why it is an error, or add any additional notes you feel are relevant. Sign and date the bottom when you are finished.
Write a Covering Letter
Attach the highlighted copies of your records. Organize them in chronological order, matching the order they are listed on the ledger. You may also want to include a short letter to the physician explaining that you are submitting corrections to your medical records, and provide your phone number or email address so he can contact you if he has any questions. Mail the documents back to the physician, or drop them off in person.
Follow Up With Your Physician
Follow up with the physician within 10 business days, which is the time frame in which the corrections must be completed. If you want to see for yourself that the corrections were made, ask to review your file in person. If the changes have not been made within this time frame, you can report the physician to the Department of Health for failure to comply.
Carrie Ferland is a practicing civil litigation defense attorney in the Philadelphia Area. As an author, her work has been featured in various legal publications for over 10 years. Ferland is a 2000 graduate of Pennsylvania State University and completed her Juris Doctorate and Master of Business Administration with the Dickinson School of Law. She is currently pursuing a Doctor of Philosophy in English.