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Tip of the week: Take a close look at your amendment policy when defining the legal health record

EHR Connection, April 2, 2007

An amendment is typically the correction of a finalized entry in a medical record that has been identified as incorrect. You should consider these corrections part of the legal record and, as such, must meet the four basic principles of a business record in order to be admissible as evidence in court.

According to the American Health Information Management Association, to meet these criteria, the record must be

  • documented in the normal course of business (following normal routines)
  • kept in the regular course of business
  • made at or near the time that the matter was recorded
  • made by a person within the business with the most knowledge of the acts, events, conditions, opinions, or diagnoses appearing in it

Because the legal health record is a critical source of information that providers use as part of the patient's continued care and treatment, it must accurately reflect the correct information. HIPAA requires covered entities to think about the following:

  • Time constraints. Facilities are required to accept, review, and respond via written correspondence to all patient requests to amend personal health information within a 60-day period (you can request a 30-day extension, if you're eligible).
  • Policy. You are required to develop a policy to meet HIPAA regulatory guidelines for accepting and processing such requests.
  • Forms. Design an amendment request form for patients to use when they want to request an amendment. Doing so ensures that your team will have the information it needs in a clear and concise manner. Forms also make it much easier to conduct analysis.
  • Designated record set (DRS). Review the DRS to ensure that all of the documents you have listed are eligible for amendment.
  • Guidelines. Establish general guidelines for an approved vs. denied amendment request.
  • Assessment. Assess system applications' effect on an approved amendment. System application limitations. Identify system limitations when processing amendments to the EHR.
  • Internal operations. Evaluate internal operation procedure for presenting amendment requests to providers, including time requirements and the procedure to amend a paper/electronic/hybrid health record.
  • Procedure. Establish a procedure to handle denied requests.

Editor's note: This tip was adapted from the new book The Legal Health Record Companion: A Case Study Approach by Deborah Adair and Karen Griffin. For more information or to order, visit HCPro's Web site at www.hcmarketplace.com/prod-4541.html.

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