A Mistake in Your Medical Record After a Car Crash

Point to the entry, not the whole chart

Locate the provider's name, visit date, note title or page, and exact wording you question. In a separate note, explain what you believe is wrong or missing and identify the few relevant pages you already have. You do not need to assemble your whole medical file just to explain the concern.

If an insurer is using the entry to question your injury history or interpret the crash, a lawyer can help compare it with the other records and assess how to address that interpretation. Ask what the actual request or response changes for the claim, and what remains unresolved. You can raise these questions before hiring counsel or with the lawyer already handling your matter.

Decide what kind of concern you have

A wrong body side or date is different from a medical opinion you disagree with, or something that changed after the visit. Start with what the entry actually says and why you question it.

An amendment request is not a way to dictate a medical opinion or erase accurate history. Discuss the medical meaning of an entry and any later changes with the treating clinician. Do not delay needed care while waiting for a response to a record request.

Ask the office how to request an amendment

Tell the office what you believe is wrong and request a correction. A provider or health plan covered by HIPAA has a formal amendment process for certain information about you, including relevant medical and billing records. That process does not cover every document it holds.

Find out which office handles the request and how to submit it. The provider or plan may require a written request and a supporting reason if it tells you about those requirements in advance. Keep your request and any receipt confirmation.

Fictional example: A visit note says 'left wrist,' but discharge instructions from the same visit say 'right wrist.' The patient identifies the provider, visit date, page, and exact wording, explains what they remember, and points to the differing instruction. That identifies a specific discrepancy for review without deciding which document should change.

If a change is accepted, read what actually changed

Check whether the office corrected the concern you raised. An amendment may be added to the original note rather than replacing it.

Read the acceptance notice to see whether all or only part of your request was accepted. The office must identify the affected records and add the amendment or a link to it.

Tell the office which doctors, insurers or others have the old information and need the amendment. It must involve you in identifying relevant recipients and get your agreement to notify them.

The office must make reasonable efforts to send the amendment within a reasonable time. That includes recipients you identify as needing it, and others it knows have the affected information if they may have relied on it—or could foreseeably rely on it—in a way that could harm you.

If the office says no, start with its explanation

If all or part of your request is denied, the office must give you a plain-language written explanation. It must tell you how to submit a disagreement or complain, and explain the option for later disclosures when you do not submit a disagreement statement. Keep the actual reply and its instructions.

A refusal does not automatically prove that your recollection is wrong. The office may rely on one of these four grounds:

• It did not create the information, unless you give a reasonable basis to believe the originator is no longer available to act on the amendment request.
• The information is not part of its designated record set.
• The information would not be available for inspection under HIPAA's access rule.
• It determines that the information is accurate and complete.

You can put your disagreement on the record

One choice is to write a statement of disagreement explaining why you disagree. The office may reasonably limit its length. If it writes a rebuttal, it must give you a copy. Later disclosures of the disputed information must include the related dispute materials or an accurate summary.

The other choice is to request that your amendment request and denial go with later disclosures of the disputed information. If you do not submit a disagreement statement, this option applies only when you make that request. The office may send an accurate summary instead.

The office must keep the amendment request, denial and any disagreement or rebuttal connected to the disputed record as appropriate. That does not make the request an accepted correction.

Keep the original, the request, and the reply separate

Do not edit the original downloaded chart. Save your explanation and supporting pages separately, and label later documents for what they are: a pending request, an accepted amendment, a denial, or a statement of disagreement. A request still awaiting a decision is not a correction the provider has accepted.

Keep a note of which version went to which recipient, if you know. Ask a lawyer how an accepted amendment or unresolved disagreement should be handled with the claim contact. Do not send a self-edited record as though it came from the provider or seek wording simply because it seems more favorable to the claim.

Keep these documents for your own reference. Use the initial 405 Injury Law website inquiry only for the information its fields request, not chart entries, medical narratives, private documents, or uploads. Ask how to provide any material later requested.

Common questions