Understanding the Process of Amending Medical Records in a Digital Age

It's important to understand the correct way to address and amend medical records, especially in the digital age where electronic health records (EHRs) play a significant role. When you need to make updates to your medical records, you cannot simply 'change' their contents. Instead, you need to follow a specific procedure to add an addendum to the records. This article explains the various methods and steps involved in amending your medical records.

Amending or Updating Medical Records

In the United Kingdom, you have several options for amending your medical records. If you need to add information to your records, you can either:

Write a letter to your doctor's practice with the update information, Visit the doctor's office and speak to a receptionist about updating your records, Or, mention the update to your next appointment with the practice nurse or doctor, If the update relates to hospital records, speak to the specialist's secretary to add the information to your records.

The simplest way to schedule a re-exam and re-record information is to visit the provider again. However, some situations might require you to make a formal request. If you need to add new information, you can do so through a patient portal. Also, consider requesting a correction if the information seems incorrect or incomplete.

Amending Electronic Health Records (EHRs)

Amending your record in an EHR platform involves a more formal process. Here are the general steps to follow:

.Submit your request writtenly, sign and date it. No verbal request is considered valid for official record-keeping purposes. Address your request to the provider who originally created the record you wish to amend. Specify which portion of the record you wish to amend and provide detailed instructions on how to make the amendment.

Given the stringent nature of EHR amendment processes, you might experience delays. Doctors and hospitals have their own systems for handling such requests, which can sometimes be lengthy. Be sure to document every step of the process and keep copies of any correspondence you send to the healthcare provider.

Common Scenarios and Legal Considerations

Updating medical records is not always straightforward, especially if there are unforeseen circumstances. For instance, mistakes might occur due to negligence or malpractice, leading healthcare providers to add information retrospectively. A frequent scenario involves medical malpractice, often stemming from a lack of informed consent.

During a procedure or surgery, patients are often pressured to sign multiple forms, including consent forms, without fully understanding the contents. Such situations can lead to an incomplete record of informed consent. If you find such a problem, you can request corrections, but healthcare providers might add the information for legal reasons or to fulfill their obligations.

It's essential to assert your rights and ensure that your objections are documented in the medical record. If a provider refers to their medical notes claiming that the information was discussed, you can provide evidence of your own objections or any relevant correspondence. This will create a clearer and more accurate record of the agreed-upon terms or objections.

The Importance of Proper Documentation

No process related to amending medical records is complete without proper documentation. Every communication and request should be in writing, and you should keep copies for your records. This ensures transparency and can be useful in case of disputes or legal issues.

Moreover, consider sending a follow-up letter to verify that your request has been noted and will be processed. If necessary, follow up with a phone call to ensure that your message has reached the relevant healthcare provider.