S2AY Network Administrative Manual
Reviewed February 29, 2016
Revised February 28, 2017
AMENDMENT TO AN INDIVIDUAL’S RECORD
POLICY: Corrections and/or additional notations to the record will be made in a way that will not jeopardize the integrity of the medical record as a legal document.
PURPOSE: To define legally acceptable, recognized ways to make corrections and/or additional notations to the record.
REFERENCE:
NYHIMA Medico-legal Manual- 1999 (most current version)
PHL -18 and Mental Health Law 33.16
CFR 45 Part 164.526
Procedure for Corrections and Omissions by Agency workforce:
· Corrections and/or amendments should be made by the person who originally omitted or made the documentation error.
· White-out, erasure, writing over, blacking out or other means to obliterate the original error are not acceptable.
· An amendment may be made on a blank progress note, letterhead, at the end of the last documentation note or as allowed in electronic record. The amendment is never to be squeezed between the two previously recorded notes already in the record.
· The amendment must be dated on the date it was written.
· When an error of omission has occurred, state “addendum” today’s date and time, record your additional notes (the addendum) and sign your entry.
· Corrections made on the date the note is written will be made by crossing through the error using a single-strike through method. The correction will be legible and initialed as noted below:
Corrections: acute dp
The patient complains of chronic abdominal pain
· Corrections made after the date the note was written will be made by crossing through the error using a single-strike through method. The correction will be legible, dated, initialed as noted below:
Corrections: acute 4/10/02 dp
The patient complains of chronic abdominal pain
· Corrections to an electronic record will be made as dictated by the software system.
Procedure for Considering Requests for Amendment to the Patient’s Medical Record (designated record set only):
· Requests for amendment to a record by the patient or legal representative must be submitted on the Amendment of Record Form to the Privacy Officer/Designee.
NOTE: Tell the client you will read / review the form with them.
· The Privacy Officer/Designee will act upon the request within 60 days of receipt. One additional 30 day extension is allowed. If the extension is necessary, the Agency will provide the individual with a written statement that specifies the reason(s) for the delay and the date they may expect to receive a decision regarding their request.
· The Privacy Officer/Designee and Program Director will process requests for amendment made by patients/legal representatives.
· The Privacy Officer/Designee and Program Director can deny the amendment request when any one of the following circumstances is determined:
o The information was not created by the Agency.
o When the information is not a part of the designated record set.
o The information would not be available for inspection under the privacy standards which includes: psychotherapy notes, information compiled in reasonable anticipation of, or for use in, a civil, criminal, or administration action or proceeding
o When the information is accurate and complete
o When changes are prohibited by law.
(For example: under certain circumstances Clinical Laboratory Improvements Amendments (CLIA) data can not be changed)
· If amendment request is granted:
o Identify and link the specific documents that are affected by the amendment. Once these documents are identified, that portion of the record will be amended.
o Notify the client in writing in Section III of the Amendment of Record Form.
o The Privacy Officer/Designee will make reasonable, timely efforts to contact those parties that the patient identified as having individually identifiable health information and needing the amendment, if applicable and,
o The Privacy Officer/Designee will notify any persons who previously received the designated record set that is the subject of the amendment, including business associates.
· If the amendment request is denied:
o Provide denial in writing no later than by the 60th day or, when an extension applies, no later than the 90th day.
o The written denial must contain:
§ The basis for denial;
§ The patient’s right to submit a written statement disagreeing with the denial and how the individual may file such a statement;
§ A statement that, if the patient does not submit a statement of disagreement, they may request that the Agency provide their request for amendment and the denial with any future disclosures of the IIHI that is the subject of the requested amendment; and
§ Agency complaint process.
· If patient disagrees with denial, request that patient complete Section IV of the Amendment of Record Form for the record. This is forwarded to the Privacy Officer/Designee.
· Recordkeeping
o The Agency will file/link the “Amendment of Record Form” to the information in question. The Form will become a part of the permanent medical record and a component of the designated record set. This will be released whenever those portions of the designated record set are released.
o Future Disclosures: The Privacy Officer/Designee must include the amended material and the Amendment of Record Form with any subsequent release, including claims review.
o When the Agency is the recipient of another Covered Entities (health plan, health provider, or clearinghouse) amendment to a patient’s individually identifiable health information, the Agency must amend documents in the designated record set to include the amendment and also inform other parties as appropriate.
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AGENCY NAME
AMENDMENT OF RECORD FORM
SECTION I
Patient/Client Name: Date of Birth: ___/___/____
Address:
Patient’s/Client’s Telephone Number: ( )_____-______.
(If the requestor is a legal representative, attach a copy of the document that proves your legal right to
access).
Type of entry you want amended: ______
Please specify what documentation (include the date) you believe is incorrect or incomplete and explain what you feel would make it complete: ______
______
Signature of Patient/Client/Legal Representative Date ____/____/______
All requests for amendment must be responded to in writing by the Agency in no more than 60 days, if the Agency requires more than 60 days to process your request to amend, they must provide you with a reason in writing prior to the 60th day. This will automatically give the Agency another 30 days (totaling 90 days) to consider your request.
SECTION II
Does the Privacy Officer or Physician (check yes or no below) accept the amendment request?
Yes (If yes, proceed to Section III) No
If no, check at least one explanation below:
____The record was not created by the Agency. It is third party information
____The designated record set was factual, complete and accurate
____The information was not a part of the designated record set
____The information is not available for inspection which includes but, is not limited to: psychotherapy
notes, information compiled for use in a civil, criminal, or administrative action or proceeding
____ The changes requested are prohibited by law
Signature of Privacy Officer/Physician Date ____/____/______
Whether Amendment is granted or denied, the Privacy Official or Director is to identify all portions of the designated record set that are affected by or linked to the amendment or denial of the amendment below: ______
This document is a part of the designated record set and will be released whenever a valid request to release any portion(s) of the record linked to this amendment is received and are specified above.
SECTION III
We have accepted your request to amend______.
You have the right to request that a copy of the amendment results (whether amendment was declined or approved) be provided to anyone to whom any portion of your designated record has been released since April 2003. If you want to exercise this right, please sign below as proof of your authorization and provide the party’s name(s) and address(es) where you want the amendment results sent.
Name Name
Address Address
Signature of Patient/Client/Legal Representative Date ____/____/______
The Agency will make timely and reasonable efforts to contact those parties that you have identified above.
SECTION IV
If your amendment request is denied, you have the right to send a statement of disagreement to the Agency. The Agency reserves the right to limit the length of your statement to the 3 lines below. If you choose to lodge a statement of disagreement, this statement will become a part of the record and will be released when a valid request for release of information is received that requires this portion of the record be sent. If you do not wish to lodge a statement of disagreement, only the request for amendment and its denial or an accurate summary of the information will be released in the future.
______
______
______
The Agency can choose to disagree with your statements in writing. If the Agency chooses to disagree, this written disagreement will also become a part of your record and will be released when a valid request for release of information is received that requires this portion of the record be sent. ______
______
______
Signature of Privacy Officer/Physician Date ____/____/______
___/____/___ Date Agency disagreement was sent to the Patient/Legal Representative
Also, if you have requested amendment be considered by another health care provider and the Agency receives the amendment information, it will become a part of the record and released when a valid request for release of information is received.