Trial lawyers rely on medical records to be accurate. Sometimes, however, a patient will ask to amend medical records. Federal law governs the process to both request and amend medical records.
 
A patient has a right to request an amendment to a medical record. The written request must be signed and dated. The request should be directed to the provider who created that record. The request must identify the part of the record to be amended and specify how it should be amended.
 
A provider has a right to decide whether to amend the medical record or not. A provider must either act on the request within 60 days or provide written notice and the reason for the delay.
 
A provider may agree to amend a record if it is not accurate or complete. A provider who agrees to amend medical records should note in the record, “Per the patient’s request, the record is amended as follows” and then make any appropriate changes. The amendment should be signed and dated. The provider should also try to provide the amendment to others who may have received the pre-amendment records.
 
If a request is denied, the provider must send a denial written in plain language (not technical medical terms) and:

1. state the reason for the denial;
    
2. inform the patient of the right and procedure to submit a written statement of disagreement;
    
3. inform the patient that he or she may, instead, ask that copies of the request to amend and the provider’s denial be included in response to future inquiries for records: and
    
4. a description of how the patient may complain to the provider or to the secretary of the Department of Health and Human Services.

A patient may write a statement of disagreement and identify the basis for disagreement. A provider can limit the length of the statement. A provider may also prepare a written rebuttal and provide a copy to the patient.
 
Whether a request to amend is accepted or denied, the provider must keep all amendment-related documents (such as the request to amend, the denial or amended record, any statement of disagreement, and any rebuttal) with the medical records.
 
If you are ever working with an attorney and medical records are involved, make sure they have the most accurate records.
 
John D. Martin is a trial lawyer and the managing partner of the Cranfill Sumner & Hartzog LLP’s Wilmington, North Carolina office. Martin concentrates his practice in the medical malpractice and professional liability defense practice groups. He has tried numerous medical malpractice and personal injury cases throughout eastern North Carolina. Many of his cases involve brain injury, birth trauma, paraplegia and wrongful death. Additionally, Martin has experience with large construction litigation, premises liability and hospital/workplace security. To contact Martin, call (910) 777-6018 or email him at [email protected].