Health Information Management

Ask the expert: In a situation involving hybrid medical records, how can we amend protected health information (PHI) that is maintained only in an electronic format?

HIM Connection, May 27, 2008

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A: If the PHI to be amended is part of a dictated report, ask the individual who dictated it to dictate a revised report, incorporating the requested amendment. You should clearly identify the revised report as a revision. The original report may be labeled “obsolete” and moved to a limited-access part of the electronic record, but it should not be deleted.
 
Editor’s note: This Q&A was excerpted from HCPro’s book, "The Privacy Officer’s Handbook." For more information or to purchase a copy, visit www.hcmarketplace.com/prod-5835.html.



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