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But when errors appear, they can cause significant problems and even risk the patient's safety or privacy. Even if the patient stays healthy, documentation errors take time and money to fix, and they could lead to punitive action from governments or lawyers.

In reality, diagnoses can be changed as needed to accurately reflect a patient's disorder. They can also be changed if a patient requests a change and the therapist agrees. One reason for such a request might due to a job or something related to their career., such as a security clearance or specific job requirement.

If you think the information in your medical or billing record is incorrect, you can request a change, or amendment, to your record. The health care provider or health plan must respond to your request. If it created the information, it must amend inaccurate or incomplete information.

Under HIPAA, patients have a right to request amendments to their medical records, but it is up to the provider to decide whether to agree to their requests. However, regardless of what the provider decides, they must respond to the patient's request.

Proper Error Correction Procedure Draw 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.

Changing a medical record to correct an error is anything but an easy process. Under federal HIPAA rulesopens in a new tab or window, 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-dayopens in a new tab or window extension.

Grave consequences of poor documentation include the following: Wrong treatment decisions. Unnecessary, expensive diagnostic studies. Unclear communication among consultants and referring physicians, which could lead to issues with follow-up evaluations and treatment plans.