Proceed With Caution When Changing Patient Records

Q. Over the years of my practice, several patients have asked me to change notes I have written in their charts. Is this legal, ethical, or otherwise appropriate?

A. There may be times when a record must be corrected to have accurate clinical information. There is a difference between correcting the record and “altering” a record. The significant differences are“ how” the correction is made and “when” the correction is made. First, if you are considering a correction or addition to existing information in a record after an adverse event, stop before proceeding and evaluate the ramifications of such a correction or addition. In most cases, a change after an adverse event will be evaluated as self-serving. That is how plaintiff attorneys will characterize it and how jurors almost always will perceive it. Thus, in such a case, consult with your risk manager and/or legal counsel.

If an inaccuracy is noted when there has been no adverse event, a correction to a medical record can properly be made if the original information is not obliterated but rather crossed through with a single line so it can still be read. The initials of the clinician and the date and time of the cross through should be added. The correct information can be added showing the time and date of the correction and the clinician's initials.

For corrections that involve more than a word or phrase, append the original entry with a statement about where to find the correct information. Then, make a new entry (in chronological order) indicating that a correction is being made and giving the correct information. Date and sign or initial both entries.

A correction or addition to the chart should never be back dated; it should always be clear when a correction or addition was made and who made it.

If you work in a facility and the facility has a policy or procedure for making record corrections, be sure to follow it. Also, some medical boards and professional organizations have established procedures for correcting medical records.

Under HIPAA's Privacy Rule, patients may request that providers who are covered entities amend their records. Providers do not have to grant the request.

Procedures and timelines for responding to record-amendment requests are spelled out in the Privacy Rule, as are the bases for denying requests. States may have shorter response times and/or more stringent procedures for responding to record-amendment requests. So, take into account your state's law as well as the Privacy Rule when responding to record-amendment requests.

Q. I am an administrator of a behavioral health care group. Our professional liability insurance is through the Psychiatrists' Program. Several of our psychiatrists are interested in moonlighting outside of the group practice. Do they need to purchase a separate insurance policy to cover them at the outside practice?

A. No, as members of the Psychiatrists' Program, these doctors do not need a separate insurance policy to cover work in an outside practice. With the group administrators' approval, coverage for these doctors can be extended for work outside their group employment (subject to underwriting approval). Also, all practitioners in a behavioral health care practice can be covered under one policy, along with the group practice itself. For more information about group coverage, call (800) 245-3333, ext. 310.

This column is provided by PRMS, manager of the Psychiatrists' Program, for the benefit of members. More information about the Program is available by visiting its Web site at<www.psychprogram.com>; calling (800) 245-3333, ext. 389; or sending an e-mail to The [email protected].▪