Patient’s Right to Request an Amendment to the Medical Record
Procedural Process – July 2006
I.
INITIATING THE REQUEST FOR AMENDMENT PROCESS:
A.
When MIS is notified that a patient wants to request an amendment to the
contents of their medical record, the patient will be sent (via fax or mail) or
given in person the standard patient form letter (Patient Letter_1) along
with the Request for Amendment form.
B.
If the patient returns the completed form, MIS will initiate the following
steps for processing the requested amendment:
C.
II.
1.
MIS will promptly log the date the Request for Amendment form
was received from the patient and review the medical record to
determine the provider(s) responsible for the documentation in
dispute.
2.
MIS will fax to the involved provider(s): the standard provider form
letter (Provider Letter_1); a copy of the Request for Amendment
form initiated by the patient; the standard Helpful Hints for
Responding form; and a copy of the VUMC Response to Request
for Amendment form. The original Request for Amendment form will
be retained by MIS to be completed when the provider is ready to
respond to the requested amendment.
3.
MIS will promptly contact the Privacy Office via email message to
report the date the Request for Amendment was received, a brief
statement of the documentation in question, and the name(s) of the
provider(s) responsible for that documentation.
4.
Within 5 days of receipt of the Request for Amendment, MIS will
contact the provider(s) and schedule a date and time on which the
provider and MIS will meet to review the request for amendment,
the medical record documentation in question, and formulate the
intended VUMC Response to Request for Amendment.
The Privacy Office will log and track the Request for Amendment in the
PACT Database. A tickler file will be set for follow up at 30 days if the
response to the request has not been processed before that date.
RESPONDING TO THE REQUEST FOR AMENDMENT:
A.
MIS will pursue a timely response from the provider through at least
weekly contact. The patient must receive a written response to the
Request for Amendment within 60 days. If a provider has not responded
to MIS within 30 days, MIS will ask the Privacy Office to intervene to
facilitate timely response.
B.
If the provider agrees to make all of the changes as noted in the Request
for Amendment:
1.
Last Revised: 07/06/06
MIS will work with the provider to correctly reflect the change in the
medical record.
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Patient’s Right to Request an Amendment to the Medical Record
Procedural Process – July 2006
C.
2.
MIS will notify the patient by sending the standard “accepted”
patient form letter (Patient Letter-2) along with a copy of the VUMC
Response to Request for Amendment form and a copy of the
pertinent sections of the medical record that reflect the change in
the documentation.
3.
MIS will save a copy of the response letter sent to the patient in the
“Letters to Patients – Responses” folder on the shared Privacy Amendment computer drive.
4.
MIS will notify the Privacy Office regarding the decision made about
the requested amendment and date the response letter to the
patient was sent.
If the provider only agrees to make a portion of the requested
amendments but denies the request to change other portions:
1.
MIS will work with the provider to correctly reflect the agreed upon
change in the medical record and complete the VUMC Response
form.
2.
MIS will scan into the electronic medical record the patient’s
Request for Amendment and the VUMC Response to Requested
Amendment under the Administrative tab. At the position of the
documentation in question in the chart, MIS will make the following
entry: “Please see Administrative document type: Request for
Amendment/Denial note of [DATE].”
3.
MIS will notify the patient by sending:
a.
the standard “partial accept and deny” patient form letter
(Patient Letter_3);
b.
a copy of the VUMC Response to Request for Amendment
form;
c.
a copy of the pertinent sections of the medical record that
reflect the change in the documentation
d.
a copy of the Statement of Disagreement form; and
e.
a copy of the How to File a Health Information Privacy
Complaint form.
4.
MIS will save a copy of the response letter sent to the patient in the
“Letters to Patients – Responses” folder on the shared PrivacyAmendment computer drive.
5.
MIS will notify the Privacy Office regarding the decision made about
the requested amendment and date the response letter to the
patient was sent.
Last Revised: 07/06/06
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Patient’s Right to Request an Amendment to the Medical Record
Procedural Process – July 2006
D.
III.
If the provider denies in full the Request for Amendment:
1.
MIS will scan into the electronic medical record the patient’s
Request for Amendment and the VUMC Response to Request for
Amendment forms under the Administrative tab. At the position of
the documentation in question in the chart, MIS will make the
following entry: “Please see Administrative document type: Request
for Amendment/Denial note of [DATE].”
2.
MIS will notify the patient by sending:
a.
the standard “amendment denied” patient form letter (Patient
Letter_4);
b.
a copy of the VUMC Response to Request for Amendment
form;
c.
a copy of the Statement of Disagreement form; and
d.
a copy of the How to File a Health Information Privacy
Complaint form.
3.
MIS will save a copy of the response letter sent to the patient in the
“Letters to Patients – Responses” folder on the shared Privacy
Amendment computer drive.
4.
MIS will notify the Privacy Office regarding the decision made about
the requested amendment and date the response letter to the
patient was sent.
PROCESSING THE STATEMENT OF DISAGREEMENT:
A.
If the patient returns the Statement of Disagreement Form it will be
processed by the Privacy Office. The Privacy Office will secure from MIS
a copy of the original Request for Amendment and the VUMC response, a
copy of the related medical record documentation, and any related
correspondence.
B.
Unless some significant new information is provided in the Statement of
Disagreement, there will be no Rebuttal Statement from VUMC. If new
information was provided by the patient, the Privacy Office will contact the
provider, or others as appropriate, to discuss whether or not a change in
the original documentation should be considered. If the new information
provided results in the need to complete a Rebuttal Statement, then the
Privacy Office will complete the Rebuttal Statement form.
C.
The Privacy Office will send the patient a response letter to close the
process, generally following the standard form letter (Patient Letter_5)
along with a copy of the How to File a Health Information Privacy
Complaint form. If a Rebuttal Statement form has been completed, the
patient will be sent a copy of the Rebuttal Statement form along with an
appropriate response letter.
Last Revised: 07/06/06
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Patient’s Right to Request an Amendment to the Medical Record
Procedural Process – July 2006
D.
The Privacy Office will save a copy of the response letter sent to the
patient in the “Letters to Patients – Responses” folder on the shared
Privacy-Amendment computer drive.
E.
The Privacy Office will enter a “HIPAA Compliance Note” into the
electronic medical record at the point of the documentation in dispute.
The HIPAA Compliance Note will identify that the patient has filed a
Statement of Disagreement regarding the response to the previous
Request for Amendment. The Privacy Office will deliver the original
Statement of Disagreement form, and the Rebuttal Statement if
completed, and any associated documentation back to MIS to be included
in the patient’s medical record.
F.
MIS will scan the Statement of Disagreement and the Rebuttal Statement,
if any, into the patient’s electronic medical record under the Administrative
document tab labeled Statement of Disagreement and/or Rebuttal
Statement (if any) associated with the original medical record
documentation in dispute and the Request for Amendment.
G.
The Privacy Office will close the PACT Database record with the final
outcome. The Privacy Office will provide periodic reports regarding this
request for amendment process to the Medical Records Committee and
the IPS Executive Committee.
Last Revised: 07/06/06
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