Health Information Technologies and Processes

Patient-generated data

  • 1.  Patient-generated data

    Posted 03-02-2020 20:01
    Hi all,

    HIM received a patient-generated data which was scanned in the system.  The patient is now requesting to remove it.  Is it appropriate to use amendment on this case?  Or is it OK to remove it as it was generated by the patient and not the provider? Thanks in advance.

    Leah Beck, RHIA
    HIM Assistant Director
    Arrowhead Regional Medical Center

  • 2.  RE: Patient-generated data

    Posted 03-03-2020 07:43

    Hi, I would have them request an amendment to the record. If it was used during their stay and part of the record, it should not be removed without process protocol. It should also be placed in the background in the chart and never truly removed.