Confidentiality, Privacy and Security

Request for Amendment

  • 1.  Request for Amendment

    Posted 9 days ago
    Edited by Joyce Adams 9 days ago
    I have received a request for amendment from a patient asking that an incorrect medication dosage noted on the nursing triage assessment be changed.  This was not part of the med list but a notation that the nurse provided in the comments of the form while talking to the patient.

    I'm not quite sure how to handle this as it was a nursing note rather than by a physician.

    I'd appreciate your thoughts on this.  Thanks!!


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    Joyce Adams, RHIT
    HIM Manager/Privacy Officer
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  • 2.  RE: Request for Amendment

    Posted 9 days ago
    Joyce...I am guessing you have your share of "simple" and "easy" amendment requests...and those that are a bit trickier.

    So first off...is it correct that the dosage information is noted in (or on) a document that is part of the DRS?  If so, that's the easy part.  Then the patient has the right to request the amendment.

    Unless this is something really noteworthy and somewhat recent, I would guess the RN would probably not know if the dosage info was written in error as this may have occurred many, many dosages ago.  Probably hard to say.  So I am guessing your process is to validate the PHI that is involved with the person making the notation to see if they believe the PHI to be correct or if it needs to be corrected.

    Is this what you typically do as part of your process?  Then if the RN believes the notation to be correct, then the patient is informed that the request is denied based on the feedback that the notation is correct.  Then as you know you would provide the requester a written response denying the amendment along with other required elements, to include that the requester may submit a written statement of disagreement, etc, etc, etc.

    Where I see problem arise is where a provide will deny the request for the amendment for whatever reasons and think the process is complete...which is incorrect and can lead to issues such as complaints.

    This is where I like having flowcharts as part of a P&P because it can really help track next steps along the way.

    Was there something specific you may be asking about as I know this was a somewhat generic response.



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    Frank Ruelas
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  • 3.  RE: Request for Amendment

    Posted 8 days ago
    Hi Joyce,
    We have had something similar happen here. We approach the nurse the same way we would approach the provider. In our case it was a notation on the allergy. The nurse selected the CT contrast, but noted that the patient had a reaction to the MRI contrast in the past. It was clearly an error on the nurse's part when she selected the CT contrast item as her notation supported the patient's claim. Once it was corrected, HIM followed up with the patient, who could validate the change from her patient portal. She was happy in the end, and we are happy that her allergies are now accurate.

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    Kathryn Wood, RHIA
    Assist Dir of Information Systems/Privacy Officer
    War Memorial Hospital
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  • 4.  RE: Request for Amendment

    Posted 8 days ago
    So nice when these can be handled quickly and easily when the person making the entry recognizes an error.

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    Frank Ruelas
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  • 5.  RE: Request for Amendment

    Posted 8 days ago
    I went ahead and handled it exactly as I would a request for a physician and it all worked out well.  Thank you for the responses! :)

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    Joyce Adams
    Him Manager/Privacy Officer
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