Medical Record Documentation Case Study
[WLOs: 3, 4, 5] [CLOs: 2, 3, 4]
Prior to beginning work on this assignment, read Chapters 5 and 9 from theFundamentals of Law for Health Informatics and Information Management textbook, review the AHIMA Amendments in the Electronic Health Record Toolkit Download AHIMA Amendments in the Electronic Health Record Toolkit
and access the Joint Commission Accreditation and Certification Manual, located in the University of Arizona Global Campus
As a new HIM professional, you have been given the task of updating the medical record documentation requirements, taking into consideration your state, Centers for Medicare and Medicaid Services (CMS), and Joint Commission requirements. As the first step in this process, your manager has requested the following:
- Identify whether your state has a medical-legal manual prepared by the state Health Information Management Association.If so, identify the cost of the manual and the section of the Table of Contents that addresses the content of the legal health record.
- Include the following items in your submission:Review your state statutes, rules, and regulations for requirements for content and retention of ambulatory records and hospital records. Include the specific statute or regulation.Review your CMS rules and regulations for requirements for content and retention of ambulatory records and hospital records. Include the specific statute or regulation.Using the University of Arizona Global Campus Library, access the Joint Commission Accreditation and Certification Manual and identify all standard sections for any reference to the health record content and documentation, authentication as well as completion requirements.
The Medical Record Documentation Case Study
- Must be two to three double-spaced paged in length (not including title and references pages) and formatted according to APA Style as outlined in the Writing Center (Links to an external site.)’s APA Style (Links to an external site.) resource.
- Must include a separate title page with the following:Title of paperSimilarity score from TurnitinStudent’s nameCourse name and numberInstructor’s nameDate submitted
- For further assistance with the formatting and the title page, refer to APA Formatting for Word 2013 (Links to an external site.).
- Must utilize academic voice. See the Academic Voice (Links to an external site.) resource for additional guidance.
- Must include an introduction and conclusion paragraph. Your introduction paragraph needs to end with a clear thesis statement that indicates the purpose of your paper.For assistance on writing Introductions & Conclusions (Links to an external site.) as well as Writing a Thesis Statement (Links to an external site.), refer to the Writing Center resources.
- Must use at least four scholarly or credible sources in addition to the weekly required reading.The Scholarly, Peer-Reviewed, and Other Credible Sources (Links to an external site.) table offers additional guidance on appropriate source types. If you have questions about whether a specific source is appropriate for this assignment, please contact your instructor. Your instructor has the final say about the appropriateness of a specific source for a particular assignment.To assist you in completing the research required for this assignment, view this University of Arizona Global Campus Library Quick ‘n’ Dirty (Links to an external site.) tutorial, which introduces the University of Arizona Global Campus Library and the research process, and provides some library search tips.
- Must document any information used from sources in APA Style as outlined in the Writing Center’s APA: Citing Within Your Paper (Links to an external site.) guide.
- Must include a separate reference page that is formatted according to APA Style as outlined in the Writing Center. See the APA: Formatting Your References List (Links to an external site.) resource in the Writing Center for specifications.
Carefully review the
Grading Rubric (Links to an external site.)
for the criteria that will be used to evaluate your assignment.
American Health Information Management Association
Amendments in the
Electronic Health Record
TOOLKIT
Amendments in the Electronic Health Record Toolkit
Copyright ©2012 by the American Health Information Management Association. All rights reserved.
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MX6662
UPDATED 2012
Contents
Foreword …………………………………………………………………………………………………………4
Authors ……………………………………………………………………………………………………………4
Introduction ……………………………………………………………………………………………………4
Issues Today ……………………………………………………………………………………………………..5
Key Terms…………………………………………………………………………………………………………5
Guiding Principles…………………………………………………………………………………………….6
Record Completion Processes…………………………………………………………………………….8
Implementation of Amendment Processes …………………………………………………………9
Record Maintenance and Legality ……………………………………………………………………..9
HIPAA Requests for Amendment……………………………………………………………………….9
Clinical Trustworthiness ………………………………………………………………………………….11
Education and Training……………………………………………………………………………………11
Audit Trails……………………………………………………………………………………………………..11
Case Scenarios ………………………………………………………………………………………………..12
Glossary …………………………………………………………………………………………………………14
References ……………………………………………………………………………………………………..15
Appendices
A: Sample Amendment Policy……………………………………………………………………16
B: Sample Deletion and Retraction Policy ………………………………………………….18
C: Sample Right to Amend Protected Health Information Policy ………………..20
D: Sample Notices of Amendments Policy ………………………………………………….24
E: Sample Questions to the EHR Vendor and IT Department ……………………..26
F: Sample Question for the Information Technology Department………………..28
G: Sample Patient Request to Amend Protected Health Information…………….29
H: Sample Patient Statement of Disagreement …………………………………………..30
Amendments in the Electronic Health Record Toolkit
Prepared By
Linda Brown, MBA, RHIA, CCS
Priscilla Komara, MBA, RHIA, CCS-P
Diana Warner, MS, RHIA, CHPS, FAHIMA
Lou Ann Wiedemann, MS, RHIA, FAHIMA,
CPEHR
Linda Young, JD, RHIA
Acknowledgements
Cecilia Backman, MBA, RHIA, CPHQ
Sara Bible, RHIA
Terri Eichelmann, MBA, RHIA
Becky Lobdell, MBA, RHIA
Heather Milam, RHIA
Foreword
The electronic health record (EHR) has not changed the fundamental
principles of health information management (HIM). Integrity and
accuracy continue to be key components to HIM. Although not new
concepts, the process for handling amendments corrections and deletions
does change when working with an EHR.
Traditional practices within the paper record support a single-line strikethrough of the original documentation. However, these practices will not
necessarily transfer to an electronic environment, and new practices should
be evaluated against organizational policy and specific system limitations.
This toolkit is designed to provide guidance to HIM professionals when
addressing the amendment functionality in an EHR. For the purpose of this
toolkit the authors have made the assumption that electronic signatures are
used in the EHR. This toolkit defines the term amendments to include
addendums, corrections, and deletions.
Deanna Panzarella, CHPS
Patti Reisinger, RHIT, CCS
Theresa Rihanek, RHIA, CCS
Sharon Slivochka, RHIA
Christine Steigerwald, MBA, RHIA
Traci Waugh, RHIA
Originally Prepared By
Terri Hall, MHA, BS, RHIT, CPC
Keith Olenik, MA, RHIA, CHP
Anne Tegen, MHA, RHIA, HRM
Diana Warner, MS, RHIA, CHPS
Lou Ann Wiedemann, MS, RHIA, CPEHR
Terri Wiseman-Kuhlman, RHIA
Introduction
Healthcare organizations must have a health record that is created and
developed to meet the requirements of a legal business record. An official
record of care is required by regulation, has specified content, and follows
accepted practices for maintaining integrity.
Though both the ASTM International and Health Level Seven (HL7)
provide guidelines for technical requirements, neither is mandated.
Therefore, EHR vendors do not have to follow these recommendations. In
the absence of these requirements the accuracy of the health record is at
risk. However, HIM professionals should review guidelines that outline best
practices that help provide direction when creating and managing this
functionality. Further guidance can be sought from state, federal, and
accrediting body requirements. HIM professionals can make recommendations
for how the amendment functionality will be applied in the organization’s
medical staff rules, regulations, and bylaws. HIM professionals must have a
fundamental understanding of how the amendment functionality operates
in the EHR systems in order to appropriately guide their organizations in
managing this function.
Organizations must have established policies and procedures to guide the
provider when changes need to be made and how to make these changes
within the health record. HIM professionals should ensure that these
policies and procedures support and maintain the integrity of the record.
Organizational processes defined in this toolkit may be different depending
on whether there are transcribed reports, direct data entry documentation,
draft documentation, final signed documents, or scanned documentation.
It is an important distinction for organizations to develop policies and
procedures regarding these different processes in order to ensure the
integrity of the health record.
4 | AHIMA
UPDATED 2012
Issues Today
Key Terms
EHRs may not provide an easy distinction between original
and edited text when changes are made to the draft or after the
record has been finalized. The edited text can often occur with
little or no versioning or track-changes functionality. These
changes often occur without the knowledge of the HIM
professional or other care providers.
Although the terms amendments, corrections, and deletions are
often used interchangeably, they do not refer to the same
actions. The intent of this toolkit is to provide some clarity
regarding these terms and guidelines for managing this
functionality within the EHR.
As providers become more comfortable with electronic
documentation and editing capabilities, changes may be made
to health record documentation on a regular basis without
HIM oversight. System functionality regarding changes may
be developed within an application of the EHR (such as a
progress note). It is not necessarily a product of poor
application architecture, but rather a design feature to allow
providers to edit health information as incorrect or incomplete
documentation is identified. The ability to ensure this
functionality is used appropriately is imperative in order to
ensure patient safety and the integrity of the health record.
HIM professionals must understand the functionality of their
EHR systems and make guidance and best practices for
amending health records available to providers. The amendment
processes will most likely vary from vendor to vendor. Not all
will handle this functionality in the same way, even with ASTM
and HL7 guidelines and EHR certifications. However, there are
some essential elements that should be present in vendor
systems to accommodate these functionalities.
Medicare Compliance Rules
The Medicare Program Integrity (MPI) Manual by the
Centers for Medicare and Medicaid (CMS) directs the
program safeguard contractors (PSCs) [soon to transition to
zone program integrity contractor (ZPICs)] and the Medicare
administrator contractors (MACs) to identify cases of suspected
fraud. In Benefit Integrity/Medical Review Determinations
section of the MPI, there is language directly aimed at
inappropriate alterations of health information.
When the PSC are reviewing health records, their focus is not
solely on coding compliance, but rather reviewing for possible
falsification of health information. The manual specifically
spells out that:
“The PSC shall evaluate the medical record for evidence
of alterations including, but not limited to: obliterated
sections, missing pages, inserted pages, white out, and
excessive late entries.” 1
While the guideline appears to be paper-based, it also applies
to EHRs. The manual defines fraud to include altering medical
documentation.
1
Amendments
An amendment is an alteration of the health information by
modification, correction, addition, or deletion. There are many
terms used that ultimately amend the health record. For the
purpose of this toolkit, the term “amendment” is the
overarching term indicating that documentation has been
altered. There are many ways that a health record may be
altered; these terms may include corrections, addendums,
retractions, deletions, late entries, re-sequencing, and
reassignment. An amendment is made after the original
documentation has been completed and signed by the
provider. It should be noted that unsigned documentation
will have changes and then be signed, the changes made
prior to the initial signature need to be tracked as well. All
amendments should be timely and bear the current date and
time of documentation.
Addendum
Entries added to a health record to provide additional
information in conjunction with a previous entry. The
addendum should be timely, bear the current date, time,
and reason for the additional information being added to
the health record, and be electronically signed.
Correction
A correction is a change in the information meant to clarify
inaccuracies after the original electronic document has been
signed or rendered complete. Corrections may also involve
removing information from one record and posting it to
another within the electronic document management system.
Retraction
A retraction is the action of correcting information that was
incorrect, invalid, or made in error, and preventing its display or
hiding the entry or documentation from further general views.
However, the original information is available in the previous
version. An annotation should be viewable to the clinical staff
so that the retracted document can be consulted if needed.
Deletion
A deletion is the action of permanently eliminating information
that is not tracked in a previous version. Most EHRs do not
allow permanent deletion.
Medicare Program Integrity Manual, Chapter 4—Benefit Integrity (Rev. 389, 09-30-11) www.cms.gov/manuals/downloads/pim83c04.pdf
AHIMA | 5
Amendments in the Electronic Health Record Toolkit
Late Entry
An addition to the health record when a pertinent entry was
missed or was not written in a timely manner.1 The late entry
should be timely, bear the current date, time, and reason for
the additional information being added to the health record
and be electronically signed.
Re-sequencing
The process of moving a document from one location in the
EHR to another within the same episode of care, such as a
progress note that was linked to the wrong date. No
annotation of this action is necessary.
Reassignment
The process of moving one or more documents from one
episode of care to another episode of care within the same
patient record, for example, the history and physical posted to
the incorrect episode. An annotation should be viewable to
the clinical staff so that the reassigned document can be
consulted if needed.
Guiding Principles
On the occasion that the health record must be amended,
policies and procedures must be in place to ensure integrity
of the health information contained in the record for patient
safety, the business record and the legal record of the
organization. Policies must outline who, when, and how
records may be amended.
Processes for receiving the patient amendment request,
identifying the PHI affected by the request, determining
whether it should be accepted or denied based on the type
of request, and notifying the patient of the outcome must be
developed. Organizations may have different processes set up
for billing requests versus clinical requests. In most
organizations, providers are responsible for determining
whether an amendment is needed to clinical information in the
health record. Amendments can be made by direct entry or
through dictation.
The system should have the functional capabilities to lock a
record from any further editing once the final signature has
been applied. In addition, the organization should clearly
define who can “unlock” a document once it has been signed.
Only one individual or department should have the ability to
unlock a report, and the functionality should be carefully
monitored and audited. An HIM professional should be
assigned the unlock function within the EHR; however, the
choice will depend on the organization and their EHR system.
6 | AHIMA
Each organization should develop guidelines regarding dual
signatures, such as residents and attending physicians. In
these cases, organizational policy will dictate when the report
and visit note is locked. If the system has already been
implemented, HIM professionals should be proactive in
addressing a system issue that does not lock the record after
final signature and request modifications from the vendor.
Organizations should define when to lock down records, for
example, 48 hours after an outpatient visit or 30 days after an
inpatient encounter. However, when there is an amendment
request, the organization must have designated staff who can
unlock the health record processes in place to ensure the
unlocked record is amended and signed, then locked again.
Each organization may develop specific guidelines that
outline what the HIM staff may amend versus what must be
sent back to the provider to correct. HIM staff may be allowed
to change demographic data such as a date of birth upon
verification, whereas all clinical amendment requests must be
sent back to the provider for updates. Regardless of the type
of change, any amendments the content of the health record
must be approved by the provider.
Another key practice would be ensuring the corrected
information does not permanently erase the incorrect
information. The new information should stand out from the
original. The system may show the new information in bold,
underlined, italics, or in a different color so that it is easily
identifiable. The system should also provide tracking
functionality to indicate when the change was made and
by whom.
Organizational policies and procedures should ensure that
only documents defined in the organization’s legal health
record and designated record set are kept in the EHR, are
used for clinical care, and are used for other secondary
reasons. Source systems, such as the transcription system,
are not consistently updated and may not have the most
current information.
The organization should have processes in place to forward
the amendments to any other place where the information
has been sent to ensure providers have the most up to date
information.
See Appendix A for a sample Amendment policy.
Addendums Practice Guidelines
Organizations should clearly define for providers that once a
document has a final sign-off, the only way to correct or
revise documentation is to provide an addendum. The
organization should have a specific policy and procedure
addressing how addendums are made in the health record.
1
AHIMA Pocket Glossary of Health Information Management and Technology
UPDATED 2012
The policy and procedure includes information regarding
where the additional information is located within the body of
the original report and the requirement that the addendum
include a separate signature, date, and timed entry. The
procedure indicates who is responsible for entering addendums
into the EHR. If the addendum is generated through a
transcription system, the interface is monitored to ensure the
addendum is correctly merged with the original report. HIM
professionals have the ability to track and trend addendums
within the EHR and provide appropriate follow-up as needed.
In addition, the organization should clearly define what type of
information is considered an addendum. Organizations may
also choose to define how extensive an addendum can be. If the
provider is correcting entire paragraphs of documentation and
editing extensive information, the organization may choose to
have the first report retracted from the EHR and ask the
provider to re-dictate or re-document a new report. In either
case, the original version should remain a part of the EHR.
Addendums should be made in the source system or where the
documentation was originally created, as well as in any longterm medical record or data repository system.
Corrections Practice Guidelines
The organization should have a clear policy and procedure
covering its system’s abilities regarding corrections. The policy
and procedure outlines the organization’s definitions of
corrections made to a signed document as well as corrections
made before the document is signed. The processes need not be
the same; they should, however, indicate who is responsible for
making the corrections in both scenarios. If applicable,
corrections should be made in the source system or where the
documentation was originally created as well as in any longterm medical record or data repository system.
Note: Organizations require policies for an instance in which the
wrong patient’s name is in the report but the information is for
the correct patient. The document should be retracted, and a
correct copy without the wrong patient’s name should be placed
in the record. Just crossing out an incorrect patient name and
adding the correct name is not enough. Every time the record is
released, a HIPAA privacy violation would occur.
Late Entries Practice Guidelines
Any provider documenting within the health record may need
to enter a late entry. The organization should clearly define
how this process occurs within its system, including the time
frame that late entries may be made. Tracking and trending
within the electronic record will be dependent on the system;
the organization should clearly understand this process. In
addition, specific policies and procedures should guide clinical
care providers on how to correctly make a late entry within the
health record. The author should document within the entry
that it is a late entry.
Typically, late entries apply to direct documentation only; for
example, physician orders, progress notes, or nursing
assessments. Dictated reports such as history and physicals,
although dictated outside of organizational time frames, would
not be considered a late entry.
Note: Some systems may not have late entry functionality. The
late entry is shown as an addendum.
Retractions Practice Guidelines
Depending on the organization’s electronic system, locked
reports may require specific interventions to retract
information; for example, only the HIM department personnel
can unlock a report, thus creating a user audit trail of instances
where information was altered. In addition, the organization
should develop guidelines for making these types of entries.
Retractions should be made in the source system or where the
documentation was originally created, as well as in any long
term medical record or data repository system.
This information should still be available in the background,
but will not display in the regular record view or be released
upon request for the record. It is important to consider that
AHIMA | 7
Amendments in the Electronic Health Record Toolkit
while this information may be in the “background” of the
EHR, it should not be reproduced on any printed versions of
the record. If the record is requested for litigation or patient
care purposes, the system should keep the retracted
information from printing as a part of the legal health record.
If the provider selects the wrong patient chart in EHR,
documents visit information, and then realizes he or she is
in the wrong chart, before signing the visit the provider will
need to delete all information entered into this patient chart
and select the correct patient chart and begin his or her
documentation over again in the correct patient chart.
The provider can copy and paste information into the
correct patient chart rather than type all of the information
over again.
If the provider has already signed the visit before he or she
realized they are in the wrong patient chart, then the provider
will be asked to alert HIM and place an addendum in the
record stating that entry was in error. The provider can copy
and paste the information keyed into the wrong patient chart
and copy it back into the correct patient chart if a policy is in
place to do so.
Retractions are different from corrections in that they change
the main point of the original documentation. A correction will
leave the original documentation intact along with the revision.
Deletion Practice Guidelines
It is recommended that system functionality never allow for
total elimination of information. If the organization allows
information to be deleted, it requires clear policies and
procedures to ensure the integrity of the health record, and it
should monitor and audit this functionality. Organizations
that allow this functionality should carefully review clinical
actions taken based on initial documentation. Many EHRs do
not allow for a total deletion of information, but rather use
the retraction method, where the information is hidden from
the general view.
When the deletion functionality is not used appropriately,
there must be an immediate follow-up and education. In
addition, organizations need to realize that audit trails are
part of the metadata and therefore discoverable for use in
litigation. Without context, the audit trail will have little value
for the organization.
Note: The ability to delete and retract information within the EHR
is dependent on the system. HIM professionals must always ask the
vendor if the system will allow for total deletion of the record.
Organizations should carefully review both functionalities within
their system and apply appropriate policies and procedures.
8 | AHIMA
Re-sequencing or Reassignment
Identifying and monitoring date of service errors is crucial to
effectively manage corrections in the EHR. Organizations
should have a process for reporting errors found within the
EHR. Whether the error is found in billing, on the floor, or in
the HIM department, there must be a point person or process
for receiving the report in order for the appropriate
correction process to take place.
All corrections made within the EHR should be documented
and tracked. The same correction elements noted in the
corrections policy below should be logged within the system,
which should also include the ability to be audited as necessary.
See Appendix B for a Sample Deletion and Retraction Policy.
Record Completion Processes
Policies and procedures should identify how and by whom
corrections are made. Facilities should develop guidelines for
changes made to signed and unsigned documents. Some type
of annotation may be made in the EDMS system so that
clinical staff will know who to contact if they feel they may
need to see the original document. HIM should designate
staff to view or print the previous version of the amended
document.
Organizations should have clearly defined policies on when
and how a record and its individual components (for
example, dictated reports, progress notes, orders, and such)
UPDATED 2012
are considered complete. System functionality should be
evaluated to determine whether or not the end-user
functionality to add information or make corrections can be
removed at a certain point in time (such as 24 hours after
discharge). Any changes that need to be made after this point
in time should be handled on a case-by-case basis and the
documentation functionality temporarily reactivated for that
specific record. Once that has been established further policies
and procedures surrounding how alterations within the record
are made should be established.
Making amendments in the EHR systems should follow the
same basic principles as correcting paper copies. HIM
professionals must consider how the information will display
electronically, on paper, and through interfaces and HIEs. For
example if color is used in the EHR, how will this display when
printed or sent through an interface? Does the document show
who updated the information and when it was updated? HIM
professionals should develop a practice policy to ensure their
organization corrects and reports errors in a consistent and
timely manner.
See Appendix E, Sample Questions for the EHR Vendor, and
Appendix F, Sample Questions for the Information Technology
Department.
Implementation of Amendment Processes
Establishing and executing the policy and procedure is vital to
accurate, timely, and appropriate management of amendments.
Some considerations for an organization’s implementation
include:
» Approval and endorsement of the policy and procedure by
senior management, medical staff, and HIM
» Identifying staff who should receive error reports for logging
and tracking purposes
» Coinsidering which staff are permitted to make corrections in
the EHR. Is this limited to certain staff within a department,
position type, or provider?
» Identifying the appropriate steps that must be taken to make
an amendment
» Identifying which systems permit amendments. Should
amendments be made within the EHR, or is there a specific
module, tool, or system used for amendments?
» Assessing potential time limitations with expectations for
• Patient requests for amendments in the designated record set
• Date of service errors especially if it affects billing and
reimbursement
» Noting that each correction should be accompanied using
verbiage such as “Entered in Error” for easy identification,
followed by, at a minimum, the date, time, purpose for
change, and who made the change
Record Maintenance and Legality
All health records must be maintained in accordance with state
and federal guidelines as well as accreditation agencies. HIM
professionals should review their state guidelines for potential
amendment and deletion requirements as well as other
appropriate federal or accrediting body rules or regulations.
HIM professionals must be aware that the term deletion, found
within state or federal record-keeping guidelines, can refer to
the act of destroying a health record once it has met the statute
of limitations for record retention. HIM professionals must
ascertain the definition of deletion when reviewing their state
guidelines and applying those to policies and procedures.
The Occupation Safety and Health Act of 1970 allows for
certain deletions. In these instances, the custodian is allowed to
delete specific information related to a family member,
personal friend, or others who have provided confidential
information regarding an employee’s health status.
In addition to the rules cited above, the HIPAA privacy rule
provides the individual the opportunity to request an
amendment to their health records. In these instances, the
covered entity has the right to review, investigate, and
potentially refuse the patient’s request.
HIPAA Requests for Amendment
The Health Insurance Portability and Accountability Act
(HIPAA) also requires the covered entity to append
information in the health record, not delete it. If accepted, a
covered entity must then inform the individual that the
amendment was made and make reasonable efforts to notify
others with whom the amendment needs to be shared.
In addition to written patient requests, requests for
amendments are now requested through EHR portals. The use
of patient portals are on the rise and are open to patients to
allow them to access their information in a secure and private
manner. Many requests identify information that needs to be
corrected; however, there are a noticeable number of requests
that appear to be frivolous. Regardless, of the nature of the
request, the following steps must be followed to ensure all
requests are responded to in a timely manner.
AHIMA | 9
Amendments in the Electronic Health Record Toolkit
Request to Amend PHI
Patients have the right to request an amendment of the
protected health information (PHI) in their designated record
set (DRS) for as long as the DRS is maintained. Therefore is it
crucial for organizations to clearly define what is in the DRS
in order to process amendment requests. In addition,
organizations may deny a patient’s request to amend PHI.
» Federal law prohibits making the PHI in question available
to the patient for inspection (psychotherapy notes).
» PHI is accurate or complete.
Written Denials
If the request for amendment is denied, the following will
occur:
Organizations may develop policies and procedures that
require patient requests for amendments to be submitted in
writing and to provide a reason to support a requested
amendment. The covered entity must act on the individual’s
request for an amendment no later than 60 days after receipt
of such a request. This means that if the request is granted,
the amendment must be made and the patient informed
within 60 days of the receipt. Covered entities should provide
an alert or the amended PHI to other individuals and
organizations with whom the PHI was shared. See Appendix
G for the Sample Patient Request to Amend the Health
Record.
» Amendment denials will be made in writing to the patient
who requested the amendment and must meet the 60 day
timeframe.
If the request is denied, a written denial must be sent to the
patient within 60 days. If the request cannot be completed
within 60 days, the organization may have a single 30-day
extension, so long as the patient is sent a written statement
stating the reason for the delay and date by which the request
will be completed.
• How the patient can complain to the organization and the
Secretary of the Department of Health and Human
Services regarding the denial
Accepted Amendments
If the request is granted, the following will occur:
» The amendment, or a link to the amendment, will be added
at the site of the original information in question
» The patient requesting the amendment will be informed
that the amendment request is accepted
» The patient will be asked to provide the names of any
relevant persons with whom the amendment must be
shared
» Any persons, including business associates that the
organization knows have the amended PHI and may have
or could foreseeably rely on such information when treating
the patient
» The amended information will also be provided with
all subsequent disclosures of the PHI to which the
amendment relates
Denial
Requests may be denied for the following reasons:
» PHI was not created by this organization (or its business
associates).
» PHI was not part of the patient’s designated record set.
10 | AHIMA
» The written denial will describe
• The basis for the denial
• The process for the patient to submit a written statement
of disagreement with the denial
• The process of requesting the organization to provide the
patient’s request and the denial with any future disclosures
of the affected PHI, if a letter of disagreement is not
submitted
• The name or title and telephone number of the designated
contact person who handles these types of complaints for
the organization
Letters of Disagreement
The patient may submit a letter of disagreement to the
organization disagreeing with the denial of all or part of a
requested amendment and the basis of such disagreement.
The organization may prepare a written rebuttal. If this is
done, the following must occur:
» The organization will identify the PHI that is subject to the
disputed amendment and append or otherwise link the
patient’s request for an amendment, the denial, the
statement of disagreement and the rebuttal.
» The organization will include the letter of disagreement and
the rebuttal with subsequent disclosures of the PHI to which
the disagreement relates.
See Appendix H for a Sample Patient Statement of
Disagreement.
See Appendix C for a sample policy on Patient Right to
Amend Protected Health Information (PHI).
Notices of Amendments
Organizations that receive notices of amendments from
another covered entity must have procedures in place to
update the PHI in the DRS in the EHR. Notices of
UPDATED 2012
amendments should be forwarded to the HIM department for
processing. The following actions should include, but not be
limited to:
» Ensuring the amendment, or a link to the amendment, will be
added at the site of the original information in question
» Processing the request immediately to ensure patient safety
» Notifying the providers on active patients for continuing care
See Appendix D for a sample policy on Notices of Amendments.
Clinical Trustworthiness
A major underlying concern is the clinical trustworthiness and
integrity of the health record. From a clinical point of view,
adding information that is not current, accurate, or applicable
into the record may have a direct impact on patient care. If
there are not processes in place when amendments are added
to the health record to share the updated information, other
providers may become confused by the inconsistent
documentation.
Education and Training
The implementation of policies and procedures combined with
readily available resources enforces accountability and
expectations of all staff. Users must be held accountable for
every entry made, especially errors and corrections. When
accountability is enforced, errors are reduced, ultimately
reducing the risk to the organization and improving overall
quality of care.
After policies have been implemented, the final critical step is
training and educating staff. Organizations should define key
personnel to receive training, such as nursing, physician,
billing, and HIM staff.
Organizations should make sure that key personnel (such as
HIM and help desk) know the available resources for the
amendment functionality and where the information can be
located. Those key personnel should also understand the
details of the policies and procedures in order to help those
with questions.
Even if the organization implements a policy that states the
complete obliteration of information will not occur,
appropriate training of personnel is required to educate on the
importance of accurate, timely clinical documentation as well
as the ramifications of errors in documentation. End users who
have privileges to document within the EHR must be held
accountable for every entry made, including errors.
Retraining is also important for those who use the amendment
functionality incorrectly such as deleting information. If a user
repeatedly uses the amendment function incorrectly, advance
corrective action may be required. It is also a recommended
practice to keep users well trained and abreast of any changes.
HIM professionals are the stewards of health information
within an organization and are charged with reconciling health
records (such as date and time) as well as certifying them as
accurate and complete. Management of amendments made
within the health record is imperative to maintain the best
quality and integrity of information possible.
Audit Trails
Organizations must determine who will track and trend all
amendments. This could fall within HIM, process
improvement, risk management, quality, or other relevant
departments. EHR systems should allow amendments and have
the ability to track corrections, and identify that an original
entry has been changed. The original entry should be viewable,
along with a date and time stamp, person making the change,
and reasons for the change.
The audit trail must capture what is amended (to include
deletions) within the health record itself and provide auditors
AHIMA | 11
Amendments in the Electronic Health Record Toolkit
with a starting point for compliance audits. Audit trails
should include the name of the user, the application
triggering the audit, the workstation, the specific document,
a description of the event (for example, deletion), and the
date and time.
amendment to the original ED note clarifying the nature of
the accident.
It is important for organizations to utilize the audit trail
function of the EHR system in order to identify and trend the
utilization of these functionalities. Reports should be
generated by provider and type in order to provide education
to individuals who may be utilizing it incorrectly. Each
organization should determine the time frame to review
reports (for example, quarterly) and results should be
reported to the compliance or HIM committee.
Questions to Ask
» When corrections are made, is the HIM department notified?
Case Scenarios
Addendum:
Case Scenario: A patient was referred from his primary care
physician for a long-term cough. He presents to the
outpatient department for a chest x-ray and sputum culture.
The resident physician provides the initial interpretation of
the x-ray film and states pneumonia and signs the report.
Seven days later the sputum culture indicates a streptococcal
infection. The radiologist returns to the original note and
completes an addendum to indicate the infection.
Concern: The new information actually changes information
within the EHR. The new information may affect the current
treatment of the patient. The infection may require a change
in antibiotics or treatment. Then new information may also
change the code assignment, which may impact billing.
Questions to Ask
» Are there processes in place to notify the primary care
physician of the change in diagnosis? Does the radiologist
have to notify the HIM department of the change?
» Does the system allow for the report to be sent
automatically when it has been updated and signed again?
» Does the system notify the coding department? Coders will
need to see if the case has been coded and, if so, if the
amendment changes the code assignment.
Corrections:
Case Scenario: A patient presents to the emergency
department (ED) and states that she fell down the stairs,
fracturing her arm. The ED physician completes his
documentation as such in the ED note. After further
discussion and follow up the patient admits that her spouse
pushed her down the stairs. The ED physician creates an
12 | AHIMA
Concern: In this case the additional information may require
additional reporting to protective services or law enforcement.
» Who will ensure the report is made to protective services or
law enforcement?
Late Entry:
Case Scenario: A nurse on the general medical/surgical floor
completes an intake assessment for a new patient to the unit.
She is called away to care for an emergency with another
patient and forgets to document the assessment within the
electronic record at the end of her shift. The next day, she
reports for her shift and enters the information at that time.
Concern: Visit documentation was not completed in a timely
manner, requiring the clinical provider to document
information about the visit as a late entry or after the visit is
locked. In order to place the documentation in the proper
place in the EHR the visit may have to be unlocked. In
addition, the late entry may not be readily identifiable. It may
or may not appear in the correct chronological order. Late
entries should be entered the on date they are made with a
note indicating the date the note should have been recorded.
Adding the note in correct order may give the illusion that
information was available for patient care.
Questions to Ask
» Did the nurse indicate that the note was a late entry by
identifying the date and time the note should have been
made?
» Did the nurse clearly document that this note was late?
Retraction:
Case Scenario: A physician is seeing patient John S. Doe in
the ED. The patient has a birth date of 12/12/89. However,
when the physician pulls up the patient record, he
inadvertently selects John S. Doe with a birth date of 12/29/87
and documents his findings. He signs the report before
realizing that he has documented on the wrong patient. The
document is now locked from editing. The physician calls the
HIM department to have the entry retracted from the
incorrect entry and placed in the correct chart.
Concern: There are two concerns; the first is patient safety
and the second is HIPAA privacy. In order to accomplish the
correction, the information must be stricken from the
incorrect record and should not be seen on the final record, or
UPDATED 2012
any printed versions of the record. The wrong information
must be removed from the incorrect health record to ensure
patient safety. The information must also be retracted to
ensure HIPAA privacy. However, since the report has been
signed and is considered locked from editing, the physician
no longer has access to remove the information within the
electronic system.
Note: The information from the incorrect health record must be
added to the correct patient health record.
Questions to Ask
» Does the EHR system have versioning so the incorrect
record is still maintained behind the scenes?
» How do you handle notifications to all who received
information on the wrong patient?
» How do you handle retractions for the records that were
interfaced to other systems or via an HIE?
Deletions:
Case Scenario: A patient is admitted to a behavioral health
facility. As a part of her counseling process the therapist meets
with the patient, enters the counseling note in the EHR, and
final signs the note. The note includes a sentence that the
patient is suicidal. Upon review, the therapist realizes that this
sentence was intended for a different patient. The rest of the
documentation within the note was accurate. System
functionality does not allow for the elimination of one
sentence; instead it shows a strike-through line, which is
inappropriate in this case. The entire document needs to be
retracted and a corrected copy created without the incorrect
sentence.
Concern: In the scenario above the provider is requesting the
removal of information from a signed document within the
health record. In order to accomplish this, the information
must be stricken from the record and should not be seen on
the final report. However, since the report has been signed
and is considered locked from editing, there is no way to
remove the information within the electronic system.
Questions to Ask:
» Does the EHR system record the deletion for tracking purposes?
Re-sequencing:
Case Scenario: A physician dictated his progress note on his
ICU patient on the same day he saw the patient. Transcription
attached the progress note to the previous day. The physician
signs the note then realizes it has been placed on the wrong
date within the patient’s current encounter and notifies the
HIM department. The HIM department moves the progress
note to the correct date.
Questions to Ask:
» Does the audit trail show how the note initially came into
the system?
» Does the audit trail show who moved the note?
Reassignment:
Case Scenario: A patient presents to the hospital for a
planned surgery. The patient has been given a pre-admission
account for all pre-operative blood work and radiology. On
the day of surgery the physician dictates the history and
physical with the date of pre-operative blood work as the
admission date and encounter number, and applies a final
signature. The report does not connect to the admission in
the EHR due to the incorrect admission date and the HIM
department must correct the admission date and encounter
number in order for the report to cross the interface and
connect appropriately in the EHR.
Concern: The concern is that the report has received a final
sign-off, thus locking the report and keeping the report from
crossing the interface. If the operating room nurses are
searching for a history and physical in the EHR there would
not be anything to view, possibly affecting the start of the
surgical procedure. There should be a way for the appropriate
organizational staff to correct the date and encounter in order
for the report to cross the interface.
Questions to Ask:
» When moving documents from one date of service to
another, does this information transfer across the interfaces?
See Appendix E for Sample Questions for the EHR Vendor
and Appendix F for Sample Questions for the Information
Technology Department.
» How do you handle notifications to all who received
information on the wrong patient?
» How do you handle retractions for the records that were
interfaced to other systems or through an HIE?
AHIMA | 13
Amendments in the Electronic Health Record Toolkit
Glossary
Additional terms factor into the guidance provided within
this toolkit. The definitions of these terms are important to
understanding the context. For the purpose of this toolkit, the
following definitions apply.
Augmentation: Providing additional information regarding
the healthcare data. HL7 uses this term instead of amendment.
Completion: The process of completing an entry in the
health record by applying the provider’s signature, either
electronic or manual. Once the signature is applied, the entry
is considered complete and the only opportunity to make
changes is through an amendment or addendum to that
entry. Organizational policy should define documentation
points required for completing an entry and how long
documents are available in an incomplete status.
Designated Record Set (DRS): A group of records maintained
by or for a covered entity that may include patient medical and
billing records; the enrollment, payment, claims adjudication,
and cases or medical management record systems maintained
by or for a health plan; or information used, in whole or in
part, to make patient care-related decisions1
Direct documentation: Text entries made into the health
record; for example, progress notes, nursing notes, physician
orders
Electronic Signature: A generic, technology-neutral term for
the various ways an electronic record can be signed, such as a
digitized image of a signature, a name typed at the end of an email message by the sender, a biometric identifier, a secret code
or PIN, or a digital signature2
14 | AHIMA
Electronic signatures frequently also have the added benefit of
ensuring the integrity of the signed document to signify that
(1) the document has not been changed since it was signed
and (2) the signer cannot “repudiate” or claim that they did
not sign the document. Electronic signatures encompass a
broad gamut of technologies and methodologies, ranging
from an “I agree” button in a click-through agreement to an
electronic tablet which accepts a handwritten signature to a
digital signature cryptographically tied to a digital ID or
certificate.
Final Signature: The process of applying the responsible
provider’s electronic signature to documentation. Once applied,
the documentation is considered complete.3 See Completion
Information: Data that have been deliberately selected,
processed, and organized to be useful4
Locked: The process by which health record entry is complete
and any changes to the entry must be made through an
amendment5
Protected Health Information (PHI): Individually identifiable
health information, transmitted electronically or maintained in
any other form, that is created or received by a healthcare
provider or any other entity subject to HIPAA requirements6
Provider: Physician, clinic, hospital, nursing home, or other
healthcare entity (second party) that delivers healthcare
Reports: Refers to transcribed reports; for example, history and
physical or operative note, not generated within the electronic
health record
1–6
AHIMA Pocket Glossary of Health Information Management and Technology
UPDATED 2012
References
AHIMA. “HIM and Health IT: Discovering Common Ground
in an Electronic Healthcare Environment.” Journal of AHIMA
79, no. 11 (Nov.–Dec. 2008): 69–74.
ASTM. E2017 – 99(2005) Standard Guide for Amendments to
Health Information. Available online at
www.astm.org/Standards/E2017.htm.
AHIMA. “Legal Health Record Leadership Model.” Available
online at http://www.ahima.org/downloads/pdfs/about/
LegalHealthRecord22.pdf.
Certification Commission for Healthcare Information
Technology. Online at www.cchit.org.
AHIMA. “Quality Data and Documentation for EHRs in
Physician Practice.” Journal of AHIMA 79, no. 8 (Aug. 2008):
43–48.
AHIMA e-HIM Work Group. “Guidelines for EHR
Documentation to Prevent Fraud.” Journal of AHIMA 78,
no. 1 (January 2007): 65–68.
AHIMA e-HIM Workgroup: Best Practices for Electronic
Signature and Attestation. “Electronic Signature, Attestation,
and Authorship (Updated).” Journal of AHIMA 80, no. 11
(Nov.–Dec. 2009): expanded online edition.
Dimick, Chris. “Field Guide: Seeing the Trees through the
Forest in 2012.” Journal of AHIMA 83, no. 1 (January 2012):
22–27.
Dinh, Angela K. “Correcting Dates of Service in the EHR.”
Journal of AHIMA 81, no.6 (June 2010): 54–55.
Health Level Seven. HL7 Electronic Health Record Work
Group. Online at www.hl7.org/ehr.
Johns, Merida. Health Information Management Technology:
An Applied Approach. 3rd ed. Chicago: AHIMA, 2011.
Nunn, Sandra. “Applying Legal Holds to Electronic Records.”
Journal of AHIMA 79, no.10 (Oct. 2008): 72–73, 80.
AHIMA e-HIM Work Group on Maintaining the Legal EHR.
“Update: Maintaining a Legally Sound Health Record: Paper
and Electronic.” Journal of AHIMA 76, no. 10 (Nov.–Dec.
2005): 64A–L.
Vigoda, Michael. “e-Record, e-Liability: Addressing MedicoLegal Issues in Electronic Records.” Journal of AHIMA 79, no.
10 (Oct. 2008): 48–52.
AHIMA EHR Practice Council. “Developing a Legal Health
Record Policy.” Journal of AHIMA 78, no. 9 (Oct. 2007): 93–97.
Wiedemann, Lou Ann. “Deleting Errors in the EHR.” Journal
of AHIMA 81, no.9 (September 2010): 52-53.
AHIMA | 15
Appendix A
Sample Amendments in the Electronic Health Record (EHR) Policy
Subject:
Sample Amendments in the Electronic Health Record (EHR) Policy
Purpose:
The health record provides a basis for patient care and for the continuity of such care. Each record
should provide documentary evidence of the patient’s medical evaluation, treatment, and change in
condition as appropriate. The purpose of this policy is to provide guidance on the instances in which
an amendment is necessary to support the integrity of the health record.
Policy:
Providers documenting within the EHR must avoid indiscriminate use of amendments as a means of
documentation. All attempts to correctly identify patients and their medical conditions should be
made prior to documenting within the record.
Definitions:
Designated Record Set: A group of records maintained by or for [insert name of organization] that
includes the medical records and billing records about patients that is used in whole or part by or
for [insert name of organization] to make decisions about patients. The term record is defined as
any item, collection, or grouping of information that includes protected health information and is
maintained, collected, used, or disseminated by or for [insert name of organization].
Protected Health Information (PHI): The demographic and health information collected from an
individual that:
1. Is created or received by a healthcare provider
2. Relates to past, present, or future physical or mental conditions of an individual, the provision of
care to an individual, or payment related to the provision of care to an individual
3. Identifies the individual or provides for a reasonable basis to believe the information can be used to
identify the individual
4. Is transmitted or maintained in any form (for example, electronic, paper, oral)
Treatment Information: Any PHI related to the provision, coordination, or management of health
care and related services.
Patient: For the purposes of this policy, “patient” refers to the patient or authorized representative of
the patient requesting information.
Amendment: An amendment is an alteration of the health information by modification, correction,
addition, or deletion. There are many terms used that ultimately amend the health record. Amendment is the overarching term indicating that documentation has been altered. There are many ways
that a health record may be altered; these terms may include corrections, addendums, retractions,
deletions, late entries, re-sequencing and reassignment. An amendment is made after the original
documentation has been completed by the provider. All amendments should be timely and bear the
current date and time of documentation and be electronically signed.
Addendum: Entries added to a health record to provide additional information in conjunction with a
previous entry. The addendum should be timely, bear the current date, time and reason for the additional
information being added to the health record and be electronically signed.
Correction: A correction is a change in the information meant to clarify inaccuracies after the original
electronic document has been signed or rendered complete. Corrections may also involve removing
information from one record and posting it to another within the electronic document management
system.
Retraction: A retraction is the action of correcting information that was incorrect, invalid, or made in
error and preventing its display or hiding the entry or documentation from further general views.
16 | AHIMA
Appendix A
Sample Amendments in the Electronic Health Record (EHR) Policy (cont.)
Subject:
Sample Amendments in the Electronic Health Record (EHR) Policy
However, the original information is available in the previous version. An annotation should be viewable
to the clinical staff so that the retracted document can be consulted if needed.
Deletion: A deletion is the action of permanently eliminating information that is not tracked in a previous
version. Refer to the Deletion and Retraction Policy.
Late Entry: An addition to the health record when a pertinent entry was missed or was not written in
a timely manner. The late entry should be timely and should bear the current date, time, and reason
for the additional information being added to the health record and be electronically signed.
Re-sequencing: The process of moving a document from one location in the EHR to another within
the same episode of care, such as a process note that was dated incorrectly. No annotation of this
action is necessary.
Reassignment: The process of moving one or more documents from one episode of care to another
episode of care within the same patient record, such as the history and physical posted to the incorrect
episode. An annotation should be viewable to the clinical staff so that the reassigned document can
be consulted if needed.
Procedure:
Provider:
1. If the provider determines that additional information is appropriate, the provider is responsible
for ensuring the total content of the documentation.
2. The provider must identify the correct patient and encounter prior to documenting within the
health record, which includes the following information:
a. Patient name
b. Date of service
c. Account number
d. Health record number
e. Original report that the addendum is to be attached to
3. Ensure that the proper format is utilized (for example, dictated report or direct data entry)
4. Edit document as appropriate
5. Ensure documentation is complete and accurate
6. Apply electronic signature
[Insert name of department]:
1. Review each amendment for appropriateness prior to attaching it to the original report
2. Attach to original report
3. Ensure the addendum has a separate date, time, and signature line
4. Through reporting, track amended records
a. Send out updated information as appropriate
b. Ensure updates were transmitted across systems
c. Track and trend amendments and report potential violations to [insert name of appropriate
committee or department]
See also:
Patient Rights to Amend Protected Health Information (PHI) Policy
Deletions and Retractions Policy
Notice of Amendment for PHI Policy
AHIMA | 17
Appendix B
Sample Deletion and Retraction Policy
Subject:
Sample Deletion and Retraction Policy
Purpose:
The health record provides a basis for patient care and for the continuity of such care. Each record
should provide documentary evidence of the patient’s medical evaluation, treatment, and change in
condition as appropriate. The purpose of this policy is to provide guidance on the instances in which
a deletion or retraction is necessary to support the integrity of the health record.
Policy:
Providers documenting within the EHR must avoid indiscriminate use of a deletion or retraction
functionality as a means of documentation. All attempts to correctly identify patients and their
medical conditions should be made prior to documenting within the record.
Definitions:
Designated Record Set: A group of records maintained by or for [insert name of organization] that
includes the medical records and billing records about patients that is used in whole or part by or for
[insert name of organization] to make decisions about patients. The term “record” is defined as any
item, collection, or grouping of information that includes protected health information and is
maintained, collected, used, or disseminated by or for [insert name of organization].
Protected Health Information (PHI): The demographic and health information collected from an
individual that:
1. Is created or received by a healthcare provider
2. Relates to past, present, or future physical or mental conditions of an individual; the provision of
care to an individual; or payment related to the provision of care to an individual
3. Identifies the individual or provides for a reasonable basis to believe the information can be used to
identify the individual
4. Is transmitted or maintained in any form (such as electronic, paper, oral)
Treatment Information: Any PHI related to the provision, coordination, or management of health
care and related services.
Patient: For the purposes of this policy, “patient” refers to the patient or authorized representative of
the patient requesting information.
Amendment: An amendment is an alteration of the health information by modification, correction,
addition, or deletion. There are many terms used that ultimately amend the health record. Amendment is the overarching term indicating that documentation has been altered. There are many ways
that a health record may be altered; these terms may include corrections, addendums, retractions,
deletions, late entries, re-sequencing and reassignment. An amendment is made after the original
documentation has been completed by the provider. All amendments should be timely and bear the
current date and time of documentation and be electronically signed.
Retraction: A retraction is the action of correcting information that was incorrect, invalid or made in
error, and preventing its display or hiding the entry or documentation from further general views.
However, the original information is available in the previous version. An annotation should be
viewable to the clinical staff so that the retracted document can be consulted if needed.
Deletion: A deletion is the action of permanently eliminating information that is not tracked in a
previous version.
18 | AHIMA
Appendix B
Sample Deletion and Retraction Policy (cont.)
Subject:
Sample Deletion and Retraction Policy
Procedure:
Deletion of information should never occur if the record is a part of any ongoing litigation.
(ADD IF APPROPRIATE FOR THE ORGANIZATION: The total elimination of information or
documentation after final signature should never occur. For instances in which the deletion function
is utilized to this end, prior approval, or notification must be obtained.)
Provider
1. If the provider determines that additional information is appropriate, the provider is responsible
for ensuring the total content of the documentation. (If the record is locked, HIM department will
unlock the record for the provider to immediately amend following the process below and then
lock again after signed.)
2. The provider must identify correct patient and encounter prior to documenting within the health
record which includes the following information:
a. Patient name
b. Date of service
c. Account number
d. Health record number
e. Original report that the addendum is to be attached to
3. Ensure that the proper format is utilized (for example, dictated report or direct data entry)
4. Edit document as appropriate
5. Ensure documentation is complete and accurate
6. Apply signature
Department [Insert department name]
1. Review each amendment for appropriateness prior to attaching it to the original report
2. Attach to original report
3. Ensure the addendum has a separate date, time, and signature line
4. Through reporting, track amended records
a. Send out updated information as appropriate
b. Ensure updates were transmitted across systems
c. Track and trend amendments and report potential violations to [insert appropriate committee or
department name]
See also:
Patient Right to Amend Protected Health Information (PHI) Policy
Amendments in the Electronic Health Record Policy
Notice of Amendment for PHI Policy
AHIMA | 19
Appendix C
Sample Patient Right to Amend Protected Health Information (PHI) Policy
Subject:
Sample Patient Right to Amend Protected Health Information (PHI) Policy
Purpose:
To ensure that all [insert name of organization] employees are aware of and comply with all laws,
statutes, rules, and regulations involving a patient’s rights to amend his or her protected health
information.
Policy:
[Insert name of organization] employees shall comply with all federal and state laws, statutes, rules and
regulations regarding a patient’s rights in relation to their protected health information. All patient
requests shall be handled in a timely manner and as set forth in this policy.
Definitions:
Designated Record Set: A group of records maintained by or for [insert name of organization] that
includes the medical records and billing records about patients that is used in whole or part by or for
[insert name of organization] to make decisions about patients. The term record is defined as any item,
collection, or grouping of information that includes protected health information and is
maintained, collected, used, or disseminated by or for[insert name of organization].
Protected Health Information (PHI): The demographic and health information collected from an
individual that
1. Is created or received by a healthcare provider
2. Relates to past, present, or future physical or mental conditions of an individual, the provision of
care to an individual, or payment related to the provision of care to an individual
3. Identifies the individual or provides for a reasonable basis to believe the information can be used to
identify the individual
4. Is transmitted or maintained in any form (such as electronic, paper, oral)
Treatment Information: Any PHI related to the provision, coordination, or management of healthcare
and related services
Patient: For the purposes of this policy, patient refers to the patient or authorized representative of
the patient requesting information
Amendment: An amendment is an alteration of the health information by modification, correction,
addition, or deletion. There are many terms used that ultimately amend the health record. Amendment is the overarching term indicating that documentation has been altered. There are many ways
that a health record may be altered; these terms may include corrections, addendums, retractions,
deletions, late entries, re-sequencing, and reassignment. An amendment is made after the original
documentation has been completed by the provider. All amendments should be timely and bear the
current date and time of documentation and be electronically signed.
Addendum: Entries added to a health record to provide additional information in conjunction with a
previous entry. The addendum should be timely and should bear the current date, time, and reason
for the additional information being added to the health record and be electronically signed.
Correction: A correction is a change in the information meant to clarify inaccuracies after the original
electronic document has been signed or rendered complete. Corrections may also involve removing
information from one record, and posting it to another within the electronic document management
system.
Retraction: A retraction is the action of correcting information that was incorrect, invalid, or made in
error, and preventing its display or hiding the entry or documentation from further general views.
However, the original information is available in the previous version. An annotation should be
viewable to the clinical staff so that the retracted document can be consulted if needed.
20 | AHIMA
Appendix C
Sample Patient Right to Amend Protected Health Information (PHI) Policy (cont.)
Subject:
Sample Patient Right to Amend Protected Health Information (PHI) Policy
Deletion: A deletion is the action of permanently eliminating information that is not tracked in a
previous version; refer to the Deletion and Retraction Policy.
Late Entry: An addition to the health record when a pertinent entry was missed or was not written in
a timely manner. The late entry should be timely and should bear the current date, time, and reason
for the additional information being added to the health record and be electronically signed.
Re-sequencing: The process of moving a document from one location in the EHR to another within
the same episode of care, such as a process note that was dated incorrectly. No annotation of this
action is necessary.
Reassignment: The process of moving one or more documents from one episode of care to another
episode of care within the same patient record, such as the history and physical posted to the incorrect
episode. An annotation should be viewable to the clinical staff so that the reassigned document can
be consulted if needed.
Procedure:
I. Request to Amend PHI
A. Patient’s Right: Patients have the right to request an amendment of the protected health information in their designated record set. However, [insert name of organization] may deny a patient’s
request to amend PHI when permitted by law.
B. Request: Patient requests for amendments to treatment information must be in writing and
submitted to the health information management (HIM) department for review and handling.
Patient requests for amendments to billing or payment information may be made in writing, in
person, or by phone to the billing department for review and handling.
C. Identification of Requesting Party: Every reasonable effort shall be made to verify the identity
of the party requesting the information (for example, picture ID, signature verification, requests
for identifying personal information, and such) and validate their legal right to the request.
D. Timeliness: The request for an amendment must have a completed action within sixty (60) days
of the receipt of the request. This means that if the request is granted, the amendment must be
made and the patient informed within 60 days of the receipt. If the request is denied, a written
denial must be sent to the patient within 60 days. If the request cannot be completed within 60
days, [insert name of organization] may have a single 30-day extension, so long as the patient is
sent a written statement stating the reason for the delay and date by which the request will be
completed.
E. General Process: HIM or the Billing Department will determine the PHI affected by the request,
log the request, and determine whether it should be denied based on the type of request or
whether it should be forwarded to the health care provider whose documentation is in question
(see F) below for a determination of whether to accept or deny the request.
F. Accepted Amendments: If the request is granted, the following will occur:
1. The amendment request will be sent to the Quality Review Department to locate any similar
information in the patient’s record to assure all information is updated.
2. The amendment, or a link to the amendment, will be added at the site of the original
information in question and be dated, time stamped, and electronically signed.
AHIMA | 21
Appendix C
Sample Patient Right to Amend Protected Health Information (PHI) Policy (cont.)
Subject:
Sample Patient Right to Amend Protected Health Information (PHI) Policy
3. The patient requesting the amendment will be informed that the amendment request is accepted
a. In writing for a treatment request
b. In writing, in person, or by phone for a billing or payment request.
4. The patient will be asked to provide the names of any relevant persons with whom the
amendment must be shared.
G. HIM or the Billing Department will provide the amended information to persons identified by
the patient, and those that [insert name of organization] knows have the PHI that is the subject
of the amendment and that may have relied on or could foreseeably rely on the information to
the detriment of the patient. The amended information will also be provided with all subsequent
disclosures of the PHI to which the disagreement relates.
H. Denials: Requests may be denied for the following reasons
1. PHI was not created by this organization (or its business associates).
2. PHI was not part of the patient’s designated record set.
3. Federal law prohibits making the PHI in question available to the patient for inspection
(psychotherapy notes).
4. PHI is accurate or complete.
I. Written Denials: If the request for amendment is denied, the following will occur:
1. Amendment denials will be made in writing to the patient who requested the amendment
and must meet the timeliness standard listed in this policy.
2. The written denial will describe
• The basis for the denial
• How the patient can submit a written statement of disagreement with the denial
• How, if a letter of disagreement is not submitted, the patient may request that [insert name
of organization] provide the patient’s request for amendment and the denial with any
future disclosures of PHI
• How the patient can complain to [insert name of organization] and the Secretary of the
Department of Health and Human Services regarding the denial
• The name or title, and telephone number of the designated contact person who handles
these types of complaints for [insert name of organization]
3. [Insert name of organization] will include the patient’s request for amendment and its denial,
or an accurate summary of such information, with any subsequent disclosure of PHI to
which the disagreement relates if the patient requests such action
J. Letters of Disagreement: The patient may submit a letter of disagreement to which [insert name
of organization] may prepare a written rebuttal. If this is done, the following must occur:
1. HIM or the billing department will route the letter of disagreement to the healthcare provider
responsible for the documentation in dispute. The healthcare provider will determine
whether to write a letter of rebuttal. If done, HIM or the billing department sends a copy of
the rebuttal to the patient.
2. [Insert name of organization] will identify the PHI that is subject to the disputed amendment
and append or otherwise link the patient’s request for an amendment, the denial, the
statement of disagreement, and the rebuttal.
22 | AHIMA
Appendix C
Sample Patient Right to Amend Protected Health Information (PHI) Policy (cont.)
Subject:
Sample Patient Right to Amend Protected Health Information (PHI) Policy
3. [Insert name of organization] will include the letter of disagreement and the rebuttal with
subsequent disclosures of the PHI to which the disagreement relates.
See also:
Deletion and Retraction Policy
Amendments in the Electronic Health Record Policy
Notice of Amendment for PHI Policy
AHIMA | 23
Appendix D
Sample Notice of Amendment for PHI Policy
Subject:
Sample Notice of Amendment for PHI Policy
Purpose:
To ensure that all [insert name of organization] employees are aware of and comply with all laws,
statutes, rules, and regulations involving a patient’s rights to amend his or her protected health
information.
Policy:
[Insert name of organization] employees shall comply with all federal and state laws, statutes, rules,
and regulations regarding a patient’s rights in relation to his or her protected health information. All
amendment notices shall be handled in a timely manner and as set forth in this policy.
Definitions:
Designated Record Set: A group of records maintained by or for [insert name of organization] that
includes the medical records and billing records about patients that is used in whole or in part by or
for [insert name of organization] to make decisions about patients. The term record is defined as any
item, collection, or grouping of information that includes protected health information and is
maintained, collected, used, or disseminated by or for [insert name of organization].
Protected Health Information (PHI): The demographic and health information collected from an
individual that:
1. Is created or received by a healthcare provider
2. Relates to past, present, or future physical or mental conditions of an individual; the provision of
care to an individual; or payment related to the provision of care to an individual
3. Identifies the individual or provides for a reasonable basis to believe the information can be used to
identify the individual
4. Is transmitted or maintained in any form (such as electronic, paper, oral)
Treatment Information: Any PHI related to the provision, coordination, or management of healthcare
and related services
Patient: For the purposes of this policy, patient refers to the patient or authorized representative of
the patient requesting information.
Amendments: An amendment is an alteration of the health information by modification, correction,
addition, or deletion. There are many terms used that ultimately amend the health record. Amendment is the overarching term indicating that documentation has been altered. There are many ways
that a health record may be altered; these terms may include corrections, addendums, retractions,
deletions, late entries, re-sequencing, and reassignment. An amendment is made after the original
documentation has been completed by the provider. All amendments should be timely and bear the
current date and time of documentation and be electronically signed.
Addendum: Entries added to a health record to provide additional information in conjunction with a
previous entry. The addendum should be timely and should bear the current date, time, and reason
for the additional information being added to the health record and be electronically signed.
Corrections: A correction is a change in the information meant to clarify inaccuracies after the original
electronic document has been signed or rendered complete. Corrections may also involve removing
information from one record, and posting it to another within the electronic document management
system.
Retractions: A retraction is the action of correcting information that was incorrect, invalid, or made in
error, and preventing its display or hiding the entry or documentation from further general views.
However, the original information is available in the previous version. An annotation should be
viewable to the clinical staff so the retracted document can be consulted if needed.
24 | AHIMA
Appendix D
Sample Notice of Amendment for PHI Policy (cont.)
Subject:
Sample Notice of Amendment for PHI Policy
Deletions: A deletion is the action of permanently eliminating information that is not tracked in a
previous version; refer to the Deletion and Retraction Policy.
Late Entries: An addition to the health record when a pertinent entry was missed or was not written
in a timely manner. The late entry should be timely, and should bear the current date, time, and
reason for the additional information being added to the health record and be electronically signed.
Re-sequencing: The process of moving a document from one location in the EHR to another within
the same episode of care, such as a process note that was dated incorrectly. No annotation of this
action is necessary.
Reassignment: The process of moving one or more documents from one episode of care to another
episode of care within the same patient record, such as the history and physical posted to the incorrect
episode. An annotation should be viewable to the clinical staff so that the reassigned document can
be consulted if needed.
Procedure:
I. Notice of Amendment for PHI
A. Amendment Notification: When [insert name of organization] is informed that an amendment
has been made by another covered entity, [insert name of organization] must amend the
protected health information in the designated record set.
B. General Process: Amendment notification will be forwarded to the HIM Department. HIMs will
determine the PHI affected by the notice. The amendment, or a link to the amendment, will be
added at the site of the original information in question.
C. Timelines: The request will be processed immediately to ensure patient safety.
D. Notifications: If the patient is still an active patient, the following will occur
1. Providers actively caring for the patient will be notified of the amendment
See also:
Deletion/Retraction Policy
Amendments in the Electronic Health Record Policy
Patient Right to Amend Protected Health Information (PHI) Policy
AHIMA | 25
Appendix E
Sample Questions for the EHR Vendor
The following is an initial set of questions the HIM professional should use when assessing the amendment functionality with
an EHR. These questions also pertain to interfaces as many EHRs are connected to other electronic systems.
Vendor Questions
Does the EHR vendor have an
established process and confirm
that system allows for amendments?
Does the EHR keep the original
version when changes are
made?
When amendments are made to
an entry, are the original entry,
current date and time, name of
the person making the change,
and the reason viewable?
Does the location of the error
point to a correction (the
correction may be in a different
location from the error if there
is narrative data entered), and
is there a mechanism to reflect
the correction?
Can the EHR system notify the
HIM department every time an
amendment is made?
Can the user determine
what changes were made in a
document without doing a
side-by-side review of the
two versions?
If changes can be seen, what
does the user see?
• Different color text
• Different font
• Strikethrough
• Record of who changed, date,
and time?
26 | AHIMA
Response to Draft
Response for Final
Response for Locked
Appendix E
Sample Questions for the EHR Vendor (cont.)
Vendor Questions
Response to Draft
Response for Final
Response for Locked
Does the printed record look
different?
• Different color text
• Different font
• Strikethrough
• Record of who changed, date,
and time?
Does the record that is copied
onto another form of media (for
example, USB drive, CD) look
different?
• Different color text
• Different font
• Strikethrough
• Record of who changed, date
and time?
Does the record that is electronically transmitted (such as
interfaces, HIE) transmit the
headers to show the changes?
When amended information is
entered into the EHR, will
providers caring for the patient
be notified?
Does the system track and run
reports for tracking changes to
the record and identify what
changes were made, who made
the changes, and when the
changes were made?
AHIMA | 27
Appendix F
Sample Questions for the Information Technology Department
In addition to the EHR Vendor questions, IT must ensure that when health records are amended in the EHR system, the
information is transmitted to all locations to which the original document was sent.
IT Questions
Does the interface send
updated documents?
Will the updated information
be sent through the HIE?
Will the updated information
be automatically sent to all
referring providers who
received the original document?
How will updated documents
received from the HIE be
handled in the EHR?
28 | AHIMA
Response to Draft
Response for Final
Response for Locked
Appendix G
Sample Patient Request to Amend the Health Record
Patient Name:____________________________________________________ Date of Birth: ____________________________
Address: ______________________________________________________________________________________________
City:______________________________________________ State:______________________ Zip Code: ________________
Home Phone: (_______)______________________________ Work Phone: (_______)________________________________
I have reviewed my health record; I do not feel the information in the record made by
________________________________________________________________________________________________ is correct.
(Name of provider)
This date(s) of service ____________________________________________should be updated with the following information:
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
This form may be returned to your clinic or mailed directly to: [insert name of organization and address/fax number]
Signature: ________________________________________________________________________Date: _________________
Provider Response
q An amendment will be made to your permanent health record.
q This request for an amendment has been made a part of your permanent record; however, your request to amend your health
record directly has been denied for the following reasons:
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Provider Signature:_________________________________________________________ Date: __________________________
If you disagree with the provider, you may submit a written statement of disagreement.
(Attach copy of Statement of Disagreement for patient)
AHIMA | 29
Appendix H
Sample Patient Statement of Disagreement
Patient Name:____________________________________________________ Date of Birth: ____________________________
Address: ______________________________________________________________________________________________
City:______________________________________________ State:______________________ Zip Code: ________________
Home Phone: (_______)______________________________ Work Phone: (_______)________________________________
Statement of Disagreement:
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
You may request that [insert name of organization] provides your request for amendment and the denial with any future request
for information.
If you want more information about our privacy practices, have questions or concerns, or believe that we may have violated your
privacy rights, please contact:
[Insert name, address and phone number of organization]
You also may submit a written complaint to the US Department of Health and Human Services. We will provide you with the address upon request. We support your right to protect the privacy of your medical information. We will not retaliate in any way if
you choose to file a complaint.
30 | AHIMA