How to Correct Errors in Medical Records

Errors in medical records can occur for a number of reasons. Unfortunately, mistakes sometimes happen, even in the medical community. For example, maybe office personnel accidentally clicked the wrong option on a drop-down menu while inputting data or perhaps miscommunication occurred during an appointment.

Medical record errors should be corrected as soon as possible to avoid any confusion, misguided treatments, or delays in benefits (e.g., insurance, social security disability, etc.). If an error is spotted, the following steps can be taken to make sure personal medical records are accurate and up-to-date.

Contact the provider

The first step in correcting a medical record error involves contacting the medical clinic or health system associated with the mistake. This can be done via phone, online portal (if available), or in person. In some cases, this is the only step required, as medical personnel may be able and willing to fix the mistake. If this is not possible, they can provide information about proper protocol for updating medical records at their specific office, which may require writing a letter or filling out a form.

Write it down

If the medical office or health system provides a form, it should be filled out and any additional information (such as a copy of the page that contains the mistake) should be attached before sending it back.

If a form is not available or if the error is more complex and needs more room for explanation than a form permits, a letter to the clinic describing the error with the following information can be sent via post:

• Full legal name
• Address
• Phone number
• Provider’s full name
• Provider’s address
• Date of service (if applicable)
• A concise explanation of the error (what needs to be corrected and why)
• A copy of the page that contains the mistake

Make a copy

A copy of everything sent to the provider should be made for personal records. This is helpful in case the error is not corrected in a timely manner or the request to fix the error is denied.

Send the request

The method of delivery (e.g., email, fax, post, online portal, in person, etc.) of the request depends on the preference of the individual office. However, it should be noted that when using a personal email, files may not be secure, and other parties may be able to view or steal information.

The provider’s responsibility

In the United States, a provider has 60 days (in Canada, 30 days) after receiving a request to act upon it; however, an additional 30 days may be granted if an acceptable reason is provided in writing to the requestor. The provider is not required to make the change; however, they are responsible for informing the requestor and any other approved parties by the requestor (other providers, business associates, etc.) in a timely manner as to whether the request is accepted or denied. If the request is denied, both the request and denial will be noted in the individual’s medical records.

Disputing a denied request

If a request is denied, a statement of disagreement may be sent to the provider. This will be added to the medical record, along with the original request and denial. A provider may respond to a statement of disagreement with a written rebuttal.

Additional sources: The Office of the National Coordinator for Health Information Technology (ONC), Verywell Health, Information and Privacy Commissioner of Ontario, Canadian Medical Protective Association, and The College of Physicians and Surgeons of Ontario