[ Thursday, December 08, 2005 ]
Amending PHI in a patient's file:
As you know, among the individual's rights that HIPAA gives to people whose PHI is held by a covered entity is the right to request the covered entity to amend the PHI in the file. This is probably requested even less often than a request for an accounting of disclosures, but it makes sense that patients should have the right to challenge and correct the PHI that other providers may rely on in treating the patients. Of course, the covered entity does not have to make the change if it determines that the original information is correct or was provided by someone else, which would prevent a patient from demanding that a bad bit of medical news be deleted so the patient could get life insurance. However, if the patient determines that wrong information is in the file (for example, a typo occurred and the patient's 120/80 blood pressure gets recorded as 120/180, or wrong patient information accidentally gets filed in a different patient's file) and notifies the provider, the provider should correct it.
If you ever do get such a request and determine that the information in the file is incorrect, there are always questions and issues of how you comply with it. If you catch a typo or misfiling prior to any possible use or disclosure of the wrong information, you can probably just correct the typo or move the information to the right file. However, you should probably note in the file (and in any other file that information was moved into or out of) the time and date of the insertion of the improper information -- if it can be determined -- and the time and date of the correction.
If you don't catch the typo or misfiling until after a use or disclosure of the information, you need to do a little more doucmentation. You should probably not simply remove the improper information; you should leave it in the file in legible form but cross it out, noting when the improper information was put in the file, when it was "deleted" or crossed out, any known uses or disclosures of the incorrect information, and any other information relevant to the cause and correction of the error. You'll also want to notify anyone else who might've received or used the wrong information. Finally, you'll need to determine if a "disclosure" has occurred for which an accounting would be required. For example, if information from patient X was put in patient Y's file, and patient Y's other physician discovered the problem when she reviewed her file, then patient X's PHI has been disclosed to patient Y's other physician.
Just something to keep in mind.
Jeff [12:50 PM]
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