Addendums and Corrections to Visit Notes
There's an error in my visit note — how do I get my doctor to fix it?
Submit a written HIPAA amendment request to your provider identifying the specific error and the correction you want. They must respond within 60 days, and if denied, you can file a statement of disagreement that becomes a permanent part of your record.
You've discovered an error in your visit note. A factual error in your medical record is more than just a typo—it's a patient safety risk. Fortunately, HIPAA gives you the right to request a correction.
Addendum vs. Alteration: The Golden Rule
When a medical record is corrected, one rule must always be followed: the original note must never be deleted or altered. The original note is a legal document, and changing it would be like rewriting history.
Addendum ✓
A new entry that is added to the record to supplement or clarify previous information. It is dated and signed, and it clearly references the original note it is connected to.
Alteration ✗
A change to the original note itself. This is strictly forbidden. EHR systems have audit trails that track every change, and altering a record can have serious legal consequences.
Key point: Any correction to your record should be in the form of a clearly labeled addendum.
How to Request a Correction to Your Visit Note
The process for requesting an amendment is straightforward, but it requires you to be clear, specific, and professional.
Step-by-Step Action Plan
- 1.Identify the Exact Error: Before you do anything, pinpoint the precise error. Write down the date of the note, the section where the error appears, the incorrect information, and the correct information.
- 2.Draft a Formal Written Request: Your request must be in writing. Include:
- • Your full name and date of birth
- • The date of the visit note in question
- • A clear description of the incorrect information
- • The correct information you want added
- • A request for an addendum to reflect the correction
- 3.Submit to the Right Person: Send your request to the provider who wrote the note and copy the clinic's Privacy Officer or Health Information Management department.
- 4.Wait for a Response: Under HIPAA, the provider has 60 days to respond. They can take a 30-day extension but must notify you of the delay.
When Your Correction Request is Denied
A provider does not have to agree with your requested correction. The HIPAA Privacy Rule allows a provider to deny a request for amendment if they believe the original note is accurate and complete.
If Your Request is Denied, You Have Two Important Rights:
You can write a statement explaining why you believe the record is incorrect. This statement must then be included in your medical record and attached to the disputed note. Anyone who views the note in the future will also see your statement.
You can request that the provider share your statement of disagreement with anyone they have previously shared the incorrect note with.
While a denial can be frustrating, submitting a statement of disagreement ensures that your side of the story becomes a permanent part of your legal medical record.
How MedicalRecords.com Helps
Request a Correction
If you've found an error in your record, we can help you draft a clear, professional, and HIPAA-compliant amendment request.
Appeal a Denial
If your provider has denied your correction request, we can help you write a powerful statement of disagreement and ensure it is properly filed.
Get an Expert Opinion
Not sure if the information is a factual error or clinical judgment? We can facilitate an expert review to help you determine the best course of action.