HOW CAN I CORRECT MY MEDICAL RECORDS?
Many potential clients ask about how they can correct errors in their medical records.
According to the Medical Board of California:
“The patient, including minors, can write an ‘addendum’ to be placed in their medical file. The original information will not be removed, but the new information, signed and dated by the patient will be placed in the file . . . .”
Health & Safety Code § 123111 states that a patient “shall have the right to provide the health care a written addendum with respect to any item or statement in their records that the patient believes to be incomplete or incorrect. The addendum shall be limited to 250 words per alleged incomplete or incorrect item in the patient’s records and shall clearly indicate in writing that the patient wishes the addendum to be come part of their records. The healthcare provider shall include that addendum if the healthcare provider makes a disclosure of the allegedly incomplete or incorrect portion of the patient’s records to any third party.”
Many prospective clients inquire about “altered” medical records. Most healthcare providers are aware that altered medical records can be used to impeach the author’s credibility, should the healthcare provider’s compliance with the standard of care is put into issue, such as during a deposition or at trial in medical malpractice cases. Physicians are usually aware that altered records can backfire and their defense to a civil case can be destroyed if their credibility can be attacked.
Incomplete or inaccurate information can hurt the patient’s credibility in child custody cases and in obtaining pain medications. For example, if a physician comments that the patient is a “drug addict,” it does not require much imagination as to how such a comment can cause serious damage to a patient in Family Law Court, or in obtaining medication for pain relief for chronic pain.
The addendum procedure at least allows the patient to mitigate his/her damages to some extent. The patient may even find himself/herself with a duty to mitigate their own damages by using the addendum procedure to correct their records and avoid “unnecessary” damages. It is hard to “un-ring” a bell, however. The patient will suffer a stigma by incomplete or inaccurate medical records regardless of an addendum.
Computerized records may allow anyone to spot a late entry. Once entered into the patient’s medical records, the healthcare provider cannot go back into the document and make alternations, and then later pretend that the alterations were contemporaneous. Late entries are always clearly identifiable in computerized medical records.
Sometimes, it will be to the patient’s advantage to use an addendum to correct incomplete or incorrect medical records. Patients should review their medical histories for accuracy. One patient wondered why his gastroenterologist recommended a colonoscopy every two or three years. The reason was that for some unknown reason, several close relatives were incorrectly said to have had colon cancer.The physician was able to correct the history in the records with the patient. Otherwise, the patient should add an addendum to his/her own medical records. The patient was told to have a colonoscopy every five years, instead of every two to three years. The physician was able to correct the history in the records with the patient. Otherwise, the patient should add an addendum to his/her own medical records.
For those prospective clients who want to sue for inaccurate/or altered medical records, the law recognizes a duty to mitigate one’s own damages by adding an addendum.
For those prospective clients who want to sue for inaccurate/or “altered” medical records, the law recognizes a duty to mitigate one’s own damages by adding an addendum; and, usually, that is the only remedy that is practical (utility vs. cost).