Chiropractic documentation gap analysis

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Proper Handling of Patient Record Amendment Requests

Patient Record Amendment Requests

In the course of a year, how many times have patients requested that their records be amended in your office? While this is not an everyday occurrence in a chiropractic office, there may be offices where this is more likely to happen than others. Regardless of the frequency, it is vitally important that the request be handled properly. Not doing so can elevate the level of risk in your office.

So, do you and your staff know the proper guidelines? I would wager that some aspects have been overlooked, whether intentionally or accidentally. Few get it spot on and even fewer have the proper documentation, training, policy, and procedure required.

Your Patients Have the Right to Request That Their Records be Amended

This guideline is a part of the HIPAA Privacy Rule 2001 (45 C.F.R § 164.526) under the Standards for Privacy of Individually Identifiable Health Information.

When a request is made, do you have a policy and procedure in place? You, as the provider, have the right to require this request to be in written form. Once you have been presented the written request, you and your staff have 60 days to comply. Should you need additional time, you may be allowed another 30 days.

When the request is approved, the provider must change the patient’s record within the appropriate time frame. This change should not consist of a deletion of the existing record; the “old” record should be stricken through (one time) and the new amended record shown. Increased penalties can be assessed if proof of any deletion of pre-existing records is evident.

One thing that the provider must take into consideration when making the amendment, is whether any other provider or entity should be notified of the changes being made. It could be that the requested change will directly affect the patient’s care from another provider, such as imaging being requested to a limb that is scheduled for surgery. If the record indicated the wrong appendage, the imaging entity would need to be notified. This obligation to communicate the changes to additional entities is called “link and notify” and is the responsibility of the amending provider. This should be clearly defined in your policy and procedure.

Can the Patients Amendment Request be Denied?

A provider can absolutely deny the patient’s request. However, an explanation for the denial must be provided in writing to the patient in a simple detailed format, within a timely manner. The patient must then have the opportunity to review the denial and to submit a written disagreement of the provider’s denial reasoning. A patient must also be notified of the option to take the issue to a higher level. This should consist of the email and phone number for the Office of Civil Rights. ( and (800) 368-1019). It is the responsibility of you the provider and your staff to inform the patient that they may take this matter to your appointed Compliance Officer or to report it to the Office of Civil Rights through their online portal.

When the record has been amended, the patient must be notified and given access to review the changes. You must also notify the patient if any “link and notify” obligations have taken place. If the patient does not agree with the changes that have been made, further disagreement can be processed as mentioned above.

If you are the provider that is being “linked in and notified” of an amendment to a patient’s medical record, you must review the patient’s record and the changes to determine if these changes alter any part of your care or treatment plan for that patient.

Accurate Documentation is Vital

Whether you are the initiating office or the receiving office for a request to amend a patient record, it would behoove you to ensure that your office has accurate policy and procedure in place. Accurate documentation is vital for the patient’s record and for your office if the chart is ever audited. Take the time to properly train your staff on this important element of compliance.

Also noteworthy is the fact that as part of the HIPAA Privacy Rule, you are prohibited from charging the patient in any manner for the amendment of the patient’s medical record. Improper handling of this policy can result in a HIPAA violation and the OCR can levy Civil Monetary Penalties for violations. The OCR, along with the Department of Justice (DOJ), will enforce HIPAA Privacy Rules and any prosecutions to violators.

KMC University feels very strongly about the need for chiropractic providers and all other providers to be compliant. If you would like more details on this or any other aspect of implementing an effective Compliance Program, please contact our team! Click here to learn more the Analysis Services offered by KMC University.

Posted by nuclearnetworking on May 7, 2018

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