Health Information Compliance Alert

Published on Sun Aug 22, 2010 PDF

Get your process under control with these 4 easy steps.

Sure, mistakes happen when processing PHI, but that doesn't mean you have to grant every request for amendment that patients throw your way. Here's how you can get a handle on your amendment request process.

You have to decide who will field patients' PHI amendment requests. The privacy officer is usually in the best position to make medical records decisions, but don't rule out your doctors, says Bret Bissey, chief compliance and privacy officer for Deborah Heart & Lung Center in Brown Mills, NJ. "Your physicians are the ones who know what's going on with the patient," Bissey notes. Strategy: Ask your physician to decide if the amendment is valid and keep her involved through the amendment process, he recommends.

There are three reasons to deny a patient's request to change information in his medical record, says Brian Gradle, an attorney with Hogan & Hartson in Washington, DC. a. The requestor isn't authorized to see the information or make changes. Only the patient or the patient's personal representative can request amendments to information in the medical record, Gradle notes. Remember: Most patients aren't trained to make decisions about what is correct when it comes to psychotherapy notes or other sensitive information, he warns.

b. The information exists outside of the designated record set (DRS). "You don't have to change information if it's not used to make treatment decisions," Bissey asserts. Remember that the DRS includes your patients' medical and billing records, Bissey notes. Example: A patient might ask you to change her satisfaction survey score, but that's secondary to the DRS, so you don't have to grant that request, he says.

c. You didn't create the record. You cannot alter any information in medical records you receive from your patients' other care providers, Gradle notes. Even with information that is obviously wrong (e.g., the previous provider marked your male patient's sex as female), you have to direct the patient back to that original source to get the information changed, Bissey advises. Example: A patient asks your physician to change the MRI results sent by the radiologist. Rather than change those results, your doc should send the patient and her request back to the radiologist, Bissey clarifies.

In order to be compliant with this section of the privacy rule, you have to respond to your patients' amendment requests within 60 days, Gradle says. And if you deny their requests, you should "give them a complete reason for the denial and let them know that they can appeal your decision," he counsels.

4. Make Note Of The Request -- Everywhere

Whether or not you decide to grant a patient's request, you need to keep all related information and forms in his medical record, Bissey advises. That way, "you can keep track of what was requested and how you handled it," he explains.

"The request, the response, the appeal and the state of rebuttal all become part of the medical record" and must accompany any disclosures of the contested information, Gradle affirms.

Tip: Save time and money by creating a summary of the process to include with disclosures, he advocates.

Don't just deny your patients' amendment requests outright -- "explain your reasoning to them and make sure they know their options," Bissey suggests. That way, you can ensure their satisfaction and provide good customer service, he says.