HospitalInspections.org

Based on review of policies and procedures, medical record, and interview, it was determined the Hospital did not require Physician #3 to implement the policy requesting to amend Health Information in the medical record for Patient #1.

Findings include:

The policy "Patient Requests to Amend Protected Health Information" requires: "...Determining whether to Grant or Deny Request for Amendment:...The request to amend will be granted unless:...The...Physician who created the record upon review determines the medical record is accurate and complete...the...physician...who concludes that it is more likely than not that the facts or omissions alleged in the request for amendment didn't occur...."

Patient #1 has Muscular Dystrophy, and was admitted on 06/27/10, after the patient became "ashen, mildly diaphoretic, and almost passed out."

Patient #1's Emergency Department Report, dictated by ED physician #3, on 06/27/10, and authenticated by the same physician on 07/01/10, had "MS" (multiply sclerosis) under the Past Medical History section, and the verbiage "the patient has full range of all 4 extremities," under the Extremities section.

On 12/08/11, the Director of Quality confirmed these statements are errors. She stated Hospital Administration had received a complaint letter on 09/16/10, regarding Patient #1, and a request for Physician #3, to amend the medical record. She confirmed on 09/23/10, the Chief Operation Officer followed up with the complainant via of a phone conversation, confirming the request.

She stated the Medical Records Department on 02/04/11, did send a request to Physician #3, asking to grant or deny the request.

On 12/22/11, the Director of Quality confirmed when she spoke with Physician #3, on 12/08/11, and he acknowledged the Medical Records Department had notified him, asking to amend Patient #1's medical record from 06/27/10. He confirmed he never contacted the Medical Record's Department to let them know whether the amendment would be granted or denied.