Oregon Health Record Amendment Denial Letter
Description
How to fill out Health Record Amendment Denial Letter?
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Addendum: An addendum is used to provide information that was not available at the time of the original entry. The addendum should also be timely and bear the current date and reason for the addition or clarification of information being added to the medical record and be signed by the person making the addendum.
No. A patient's record should be complete and accurate to ensure they receive appropriate care. Patients can question the content of their records, but not on the basis that it is upsetting or that they disagree with it.
A patient has the right to request an amendment to his or her health record per 45 CFR §164.526 of the HIPAA Privacy Rule, and it is the policy of this organization to respond to any amendment requests in accordance with this rule.
Changing a medical record to correct an error is anything but an easy process. Under federal HIPAA rules, patients have the right to request that doctors fix errors, but the provider has up to 60 days to respond, and can ask for a 30-day extension. The provider also can refuse, but must specify the reason in writing.
Proper Error Correction ProcedureDraw line through entry (thin pen line). Make sure that the inaccurate information is still legible.Initial and date the entry.State the reason for the error (i.e. in the margin or above the note if room).Document the correct information.
Any corrected record submitted must make clear the specific change made, the date of the change and the identity of the person making that entry. Note that only the attending providerthat is, the provider who saw the patient and documented the initial note for the visit in questionmay amend the medical record.
Proper Error Correction ProcedureDraw line through entry (thin pen line). Make sure that the inaccurate information is still legible.Initial and date the entry.State the reason for the error (i.e. in the margin or above the note if room).Document the correct information.
Consequently, patients frequently ask about whether they have the right to remove a diagnosis from their medical records. But, can they do this? The answer to this question is NO.
Reasons for Denial.The provider who received the amendment request had not created the original record. The record was created at another office. There is an exception if the creator is no longer available and the mistake in the record is apparent.
General concerns about psychological or emotional harm are not sufficient to deny an individual access (e.g., concerns that the individual will not be able to understand the information or may be upset by it). In addition, the requested access must be reasonably likely to cause harm or endanger physical life or safety.
