How to get a diagnosis removed from medical records?

A patient’s medical record is the first and essential tool for accurate clinical decision-making and care provision. Not only that, medical records serve their purpose in legal issues and reimbursements.

Although it is the duty of the doctor to document every detail with utmost accuracy, there can be incoherencies in the medical records, a history of diagnosis that is embarrassing for the patient and might hinder the establishment of further accurate diagnosis and patient care, or simply the patient doesn’t agree with the doctor’s opinion and wants to omit that part.

Consequently, patients frequently ask about whether they have the right to remove a diagnosis from their medical records. But, can they do this? The answer to this question is NO.

Patients’ rights

As per Health Insurance Portability and Accountability Act (HIPPA), patients have the right to correct errors in their medical records, but they cannot omit anything completely. If found any mistakes, HIPAA allows the patients to request the medical staff changes and amend the document by adding extra information.

HIPPA doesn’t provide the patients the right to control their Protected Health Information (PHI) disclosure for medical treatment. Therefore, if a patient doesn’t want to share his previous information with the new doctor or is interested in only sharing a selective part of his records, this is impossible. 

Upon request, the doctor will not remove old information provided in the medical records, but he will go for extensive examination and updated test results.

If the patient’s concerns were genuine, the doctor would add new notes about ruling out the previous diagnosis; this includes establishing the new diagnosis and arguing the possible reasons for changing the diagnosis.

Type of errors subjected to amendments

The type of errors for which patients can request amendments or changes include:

Error in spelling or text style

Inevitable spelling mistakes might require immediate change, but the spelling mistakes that do not affect a patient’s medical care or medical record should be left out.

Errors in spelling of patient’s name

If the spelling of the patient’s name is not correctly documented, your doctor can correct it easily. The patient should not ignore such mistakes as they will affect the proper sharing of medical records and reimbursements.

Errors in demographics

Any incorrect information relevant to a patient’s demographics should be corrected instantly. If the patient doesn’t pay any attention, it will be a problem for the medical team to contact the patient, and wrong information will be shifted to the patient’s future medical records.

Inaccurate diagnosis

The patient may get wrongly diagnosed at some point in his life; such a diagnosis can affect a patient’s present health care. It is crucial to make the necessary changes to medical records or modifications to his medical record.

READ MORE: How does HIPAA protect personal medical ​records?

Requesting the changes

Healthcare systems have patient portals through which patients can access all of their medical records or even request a medical record copy. Once a patient goes through his medical record, his records can be corrected immediately after discussing with the doctor. However, if that doesn’t work, the patient must follow the proper procedure to make any changes to the medical record.

Note: Not every request needs to be accepted. The health care provider can deny a patient’s request for many reasons. In case of psychiatric diagnosis, drug abuse, sexually transmitted disease, or violent behaviors, the request may not be entertained and rejected. Removing such a record can affect medical treatment.

Request procedure

For requesting the changes in medical records, the patient has to contact his healthcare providers and ask for an amendment form. He has to fill out the form and staple it with his application. 

In the application, the patient should write about the corrections needed and valid reasons for the corrections. Also, it is better if the patient attaches a copy of the medical record pages that need correction and highlights those lines. It will be easy for the person in charge to understand the request and make changes accordingly.

Generally, the provider will work on the amendment requests within 60 days and inform the patient about acceptance or denial of the request.