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Your client has reviewed his health record. You answered his questions to ensure he understood the record, but he wants corrections made to a consulting physician's note. What do you do?

User Jwolf
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1 Answer

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Final answer:

When corrections to health records are requested, factual inaccuracies must be corrected while differing opinions on medical evaluations are more nuanced and may lead to added patient statements rather than changes by the physician.

Step-by-step explanation:

When a client requests corrections to be made to a physician's note in their health records, the first step is to understand the nature of the corrections needed. Whether these are factual inaccuracies or misunderstandings, each type of correction would be handled differently. If the inaccuracies are factual, such as a wrong date or misstated medical history, the corrections should be made as patients have the right to accurate information in their health records. However, if the disagreement is about a physician's medical opinion, that is more complex, as medical opinions are interpretations based on the physician's expertise and information at the time.

To address such concerns, you might facilitate a discussion between the client and the consulting physician. If the client still believes their record is incorrect, they may add a statement to their record indicating their viewpoint. In addition, the client has the right to request amendments to their health records under the Health Insurance Portability and Accountability Act (HIPAA), and the healthcare provider is obligated to respond to this request within a certain timeframe, typically 60 days. However, healthcare providers are not always required to make the requested changes.

Any changes to health records should be made with careful consideration, making sure not to compromise the integrity of the medical record and adhering to professional standards and legal requirements.

User Rob Mason
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