Amending records

June 4, 2004

One of my patients would like me to amend information in her medical record. Is this permitted under HIPAA?

Q:One of my patients would like me to amend information in her medical record. Is this permitted under HIPAA?

A: Yes. Patients have the right to make this request. But you can refuse the request if (1) you didn't create the record in the first place, and the one who did is no longer available to act on the request; (2) the information in question isn't part of the record; (3) the patient's right to access is limited by circumstances (pending litigation against you, for example); or (4) the information is accurate and complete as is.

If you refuse to amend a patient's record, you must notify the patient in writing. Your letter must contain the reason for the denial; notice of the patient's right to submit a statement of disagreement, which can be placed in the medical record; and procedures for filing a complaint with the Department of Health and Human Services.