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/policies/administrative/uw-health-administrative/health-information-management/614.policy

201605123

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UWHC,UWMF,

Policies,Administrative,UW Health Administrative,Health Information Management

Amendment of the Medical Record (6.14)

Amendment of the Medical Record (6.14) - Policies, Administrative, UW Health Administrative, Health Information Management

6.14

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Administrative (Non-Clinical) Policy
This administrative policy applies to the operations and staff of the University of Wisconsin Hospitals and
Clinics Authority as integrated effective July 1, 2015, including the legacy operations and staff of UWHC
and UWMF.

Policy Title: Amendment of the Medical Record
Policy Number: 6.14
Effective Date: May 1, 2016
Chapter: Health Information Management
Version: Revision
I. PURPOSE

To provide a mechanism for appropriately amending a medical record at the request of the patient or a
healthcare practitioner.

II. DEFINITION

Clinician Author: A clinical staff member who has the authority and responsibility for creating and/or
authenticating patient health record entries. Examples include: Physicians, Advance Practice Nurses,
Certified Nurse Midwives, Physician’s Assistants, Psychologists, Pharmacists, Speech Language
Pathologists, Audiologists, Licensed Clinical Social Workers, and any other health care professional
licensed, credentialed, and/or approved by UW Health to document in the patient health record. Clinician
Author also includes residents and students in approved health occupation programs under the supervision
of a clinical staff member. It is also recognized that others besides Clinician Authors may assist in the
documentation process, but they do not have final responsibility for the documentation; this responsibility
is assigned to the author who finalizes or authenticates the patient health record entry.

III. POLICY
A. All patients or their legally authorized representatives have a right to request an amendment of
the information contained in their UW Health medical records. However, only UW Health staff is
authorized to make the amendment pursuant to the procedures listed below.
1. A legally authorized representative is anyone who is authorized under state law to request
an amendment to his or her medical records. State law determines the age and ability of
an individual to request an amendment to a medical record. Any questions about the age
and/or ability of an individual to request an amendment to a medical record should be
directed to the Document Integrity Manager, Health Information Management (HIM).
2. The "medical record" includes records used to provide or document treatment decisions
about the patients. The medical record includes, but is not limited to the paper and
electronic medical records, as well as X-rays, audio/videos and other images.
B. All patient requests for amendments to the medical records should be directed to the HIM
Department.
C. UW Health has the right to deny a request to amend the medical record under certain conditions.
All denials will be documented on the "Request for Amendment of the Medical Record" form and

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scanned into the patient record under the media tab (amendment form), and a copy sent to the
patient.
D. Staff may also have a clinical or business need to amend medical records.
IV. FORM USED

Patient Request for Amendment form (UWH#4004921)

V. PROCEDURE
A. Patient Requested Amendment of Medical Records
1. Request Process
a. Patients or their legally authorized representatives who believe information in
their medical record is incomplete or incorrect may request an amendment of the
information by completing the Patient Request for Amendment form (UWH#
4004921). Legally authorized representatives may only request an amendment
when the patient has been declared incompetent or incapacitated.
i. Patients may request and submit an amendment form to the HIM
department at Mail: Record Quality Attn: Patient Amendment 8501
Excelsior Drive Madison WI 53717
ii. Fax: Attn: Patient Amendment 608-203-1440
iii. Inter-Departmental Mail: Patient Amendment, mail code 2427
b. A copy of amendment form and the questioned medical record information will
be provided to the clinician author who will determine whether the amendment
request will be approved or denied.
2. Review/Response Process
a. UW Health must review and either approve or deny a patient's request for an
amendment within sixty (60) days after receipt of such a request.
b. UW Health must review and either approve or deny an amendment related to
mental health records, thirty (30) days after receipt of such a request.
c. Any request that is unable to be completed within the required timeframe will
have a letter sent to the patient indicating a 30 day extension has been activated
and the reason for the extension.
3. Approval Process. If the requested amendment is approved:
a. The amended document with the author's signature will be maintained in the
patient's record permanently.
b. A notation regarding existence of the amendment/correction form will be made
in the record linking the two documents if the original document cannot be
amended.
c. Copies of the amended document will be furnished to those individuals or
organizations identified by the patient as having received protected health
information about the patient and needing amendment within thirty (30) business
days.
4. Denial Process
a. UW Health may deny the request for amendment if it is determined that the
document:
i. Was not originally created within UW Health;
ii. The original clinician author is no longer available to act on the
requested amendment;
iii. Is not part of the UW Health medical record;

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iv. Would not otherwise be available for patient access under Federal and/or
State law; or
v. Is accurate and complete per the author.
b. If request is denied in whole or in part, UW Health must provide the patient with
a written explanation that includes:
i. The reason for the denial;
ii. An explanation of their right to submit a written statement disagreeing
with the denial and instruction on how to file a statement of
disagreement;
iii. Inform the patient that if they do not choose to file a statement of
disagreement, they may alternatively request, in writing that UW Health
provide copies of both the request and denial forms in any future
disclosures;
iv. A description of how the patient may file a complaint with UW Health
pursuant to the complaint procedures as listed in UW Health's Notice of
Privacy Practice.
c. Statement of disagreement. UW Health will allow the patient to submit a written
statement disagreeing with the denial of all or part of the requested amendment
and the basis of the disagreement. UW Health limits the length of this statement
to one written or typed page.
d. Rebuttal process. UW Health may choose to prepare a written rebuttal to the
patient's statement of disagreement, but if done, the patient will be provided with
a copy.
B. Making the amendment to the patient's paper and electronic medical record, whether it was
requested by the patient or identified by the Clinician Author:
1. Dictated - electronic medical record correction
a. The document is recreated to include the amendment and is re-signed by the
Clinician Author.
b. A notation will be made by the Clinician Author to indicate that the document
has been amended/corrected.
c. The original document is removed from the medical record and is scanned into a
file that is available to HIM staff only. The file will be retained permanently.
2. Paper record
a. The document is recreated to include the amendment and is re-signed by the
Clinician Author.
b. The original document is removed from the medical record and is scanned into a
file that is available to HIM staff only. The file will be retained permanently.
3. Direct note entry into Health Link
a. If correction is required to any data element within an encounter, and the
encounter is closed, the correction must be done via an addendum.
b. The author of the note is encouraged to add his or her own entry by following the
instructions in the Health Link Chart Corrections Guidelines located on U-
Connect.
c. The record will identify the original note as a "previous version" and the addenda
note will become the final version.
d. HIM may also addend a document for a Clinician Author and assign the
Clinician Author to co-sign the addenda document, if needed.
e. If circumstances require that the note be hard deleted, author should contact HIM
to coordinate the delete.
4. Handwritten entries

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a. Any amendments to a hand entry made in the medical record shall be crossed out
with a single line, initialed by the person amending the entry and date. The
correct word(s) shall be written above the incorrect entry or as close to the
amended entry as possible.
b. If amendment requires more space than that allowed on the original document, a
separate document will be created and placed directly above the original.
c. Notation that a separate amended document
exists will be written directly above the crossed off entry indicating where
amended report can be located.
d. The amended document will clearly indicate that it is an amendment to the
specific original document.
5. Future Disclosures
a. UW Health will include the request for amendment and its denial with any
subsequent disclosure or PHI only if the individual has requested such action.
b. If a statement of disagreement has been submitted, UW Health will include the
Statement of Disagreement with any subsequent disclosure of the PHI associated
with the disagreement.
C. Correction of Entire Contact/Encounter
1. Duplicate Medical Record Numbers
a. Notify HIM of the double number by completing the HIM - Duplicate patient
link in the Health Link front page or send an e-mail to epicdupmr@uwhealth.org
b. Continue documenting the patient's care under the medical record number
assigned on admission.
i. HIM will combine the two records after the patient is discharged.
ii. If there is a compelling reason to merge the records while the patient is
still in-house and the medical record number being kept is not the
number the patient is admitted under, the merge will be attempted on the
next business day, M-F. (All users must not be accessing the record
during the time the merge is conducted). Note: chart alerts will be placed
on both medical records until the merge has been completed. This is
necessary to allow all ancillary systems to make corrections in their own
system to allow results to file correctly. For urgent requests after hours
and on weekends, please open an incident in Service Now and direct it to
HIM-Identity.
iii. Whenever possible, the medical record number the patient is admitted
under will be retained. In these instances the merge can be done while
the patient is in house, however it can only be done when all other users
are not accessing the patient's electronic record.
2. Overlay (one medical record contains two or more patients' demographic and/or clinical
information)
a. Notify HIM by opening an incident ticket in Service Now and direct it to HIM-
Identity and provide all known details - names, medical record numbers, dates of
birth, etc. The Identity-Team will be paged 24 X 7.
b. Discontinue documentation on wrong patient's medical record as soon as the
overlay is identified.
c. Discharge the patient (HUC/Access Management). Readmit patient under the
correct medical record number with the current date and time (do not back date
the admission) and begin documentation.
i. HIM will move the erroneous admission to the correct medical record on
the next business day or as soon as possible. This is necessary to allow

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all ancillary systems to make corrections in their own system to allow
results to file correctly.
ii. When an inpatient contact cannot be immediately moved due to Health
Link issues – chart alerts will be placed on both medical record numbers
and when needed all patient documentation from that admission will be
printed and scanned into the correct patient's electronic record in Health
Link.
VI. COORDINATION

Sr. Management Sponsor: VP, CIO
Author: Director, Health Information Management; UW Hospitals Compliance Officer

Approval Committee(s): Medical Records Committee; UW Health Administrative Policy and Procedure
Committee

SIGNED BY

Ronald Sliwinski
President, University of Wisconsin Hospitals
Chief of Clinical Operations


Revision Detail:

Previous revision: 072015
Next revision: 052019