Part 2: Basic Patient Rights (FAQ 30 of 65)
Right to Request Amendment
30. Can I Ask that Incorrect Information be Removed From My File?
Yes, but it may not be that easy. A HIPAA covered entity does not necessarily have to remove incorrect information. It can mark the information as incorrect and add additional notes that show the correct information.
There is a reason for this policy. Suppose that your doctor suspects that you have an infection. Before the test results come back, the doctor prescribes an antibiotic. When the test later shows that you didn't have the infection, the doctor tells you to stop taking the antibiotic.
Now suppose that you ask the doctor to remove the initial diagnosis of an infection. If the information is totally removed, it will be impossible for the doctor to explain or justify the prescription for an antibiotic. It may not be appropriate to remove the entire incident from the record because the doctor will be unable to explain the treatment provided or the bill for the services. The doctor also needs to keep the record in the event that there are complications from the drug. The doctor rightly needs a history of the treatment for his/her protection for both legal and medical reasons. Your health record isn't just about you. It's about your provider too.
Health care providers are typically nervous about removing information from health records. For the most part, they have a reasonable concern for the reasons explained above. However, when the information in your health record is not about you, the provider's concern is weaker. When the information in your record is not about you and the presence of the information did not affect your subsequent care, the argument for removal is stronger. For example, if your record includes a lab slip belonging to another patient, it may be appropriate for the record keeper to remove the slip entirely and put it in the right record.
However, if the incorrect information did affect your treatment -- even if that treatment was inappropriate -- then retaining some or all of the incorrect information (suitably marked as incorrect and including a full explanation) may be legally and medically justifiable. You may be able to negotiate with the provider about how the information should be marked or otherwise segregated from your medical record.
The problems faced by medical identity theft victims seeking amendment of their record can be particularly difficult. See the World Privacy Forum's Medical Identity Theft Page or go directly to our FAQ for identity theft victims at www.worldprivacyforum.org/FAQ_medicalrecordprivacy.html.