Tip of the week: Understand how to amend PHI
HIM Connection, February 12, 2008
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Amending protected health information (PHI) means adding new information to the individual's record. You should not destroy or obliterate the original information. If the PHI to be amended is part of a dictated report in an electronic or hybrid record, ask the individual who dictated it to dictate a revised report, incorporating the requested amendment. Providers should clearly identify the report as a revision. The original report may be labeled obsolete and moved to a limited access part of the electronic record, but you should not delete it.
You may also need to amend a scanned record when the original paper version has been destroyed. Although it's impossible to change the original scanned document, it is possible to add a new document that contains the revision. Providers must clearly identify the new document as a revision and must index it to the appropriate part of the patient's record. You may move the original electronic document to a limited access part of the patient's record, but you should not delete it.
Editor's note: This tip was adapted from HCPro's book, The Privacy Officer's Handbook. For more information, visit http://www.hcmarketplace.com/prod-5835.html or call 800/650-6787.
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