Migraine Medical Records: How to Request Corrections
Getting copies of your medical records is important for many reasons. One is the opportunity to spot and deal with errors. While the idea of seeking a correction to your medical records seems intimidating, it's an important step to take to make sure you get the best, safest care possible.
Federal law gives patients the right to ask for an amendment to their medical records to correct errors. Doctors are not required to make corrections if they believe the information is accurate. But even if your doctor disagrees with you, the amendment request will be added to your records and go with them wherever they go in the future. New healthcare providers will see both what the doctor put in your record and your amendment request.
By way of example, let's pretend you got a copy of your medical records from your Headache Disorders specialist and started reading through them. You noticed the doctor had recorded at an August 1, 2013, office visit that Topamirate was reducing the frequency of your Migraine attacks and was well tolerated. But in reality, while Topamirate was/is helping with the frequency of your Migraine attacks, you've been experiencing unrelenting nausea, tingling in your extremities and cognitive issues.
Here are the steps to take to seek an amendment to your medical records:
- Request a copy of your medical record, if you haven't already done so.
- Ask the health care provider whether they require you to fill out a form to seek an amendment. If so, get a copy of the form and fill it out.
- Ask the health care provider to whom you should direct your amendment paperwork. Get not only the correct mailing address, but also the name and phone number of the person who handles these issues in the office.
- Write a letter explaining the error in your medical record. Submit this letter with the form, if one is required, or instead of the form if one is not required.
- Make a copy of the page(s) in your medical record where the error appears and highlight the section(s) in question for clarity.
- Make photocopies of all forms, letters and pages in your medical record in case they don't receive your request and for your own files.
- Submit all relevant paperwork (form, request letter, relevant pages of medical records) to the health care provider who created the record in question.
- Follow up to make sure the amendment paperwork was received and processed.
- Ask the doctor's office staff to send copies of your records with the amendment to your other health care providers.
Tips for writing your letter:
- Include the following information: Your name, contact information, date of birth, Social Security number and/or patient ID number.
- Be as specific as possible about the error.
- State that you are requesting an amendment to your medical record. Include the date of the visit, the type of record (office visit, lab report, etc.) and exactly what you believe is incorrect: "I request an amendment to the doctor's notes from my August 1, 2013, office visit stating Topamirate is reducing the frequency of my Migraine attacks and is well tolerated."
- Write out a statement that addresses the incorrect information: "Please add the following statement to my records: 'The patient is experiencing a reduction in Migraine attacks on Topamirate, but the patient is not tolerating the medication well. The patient has been experiencing ongoing nausea, tingling in the extremities and cognitive dysfunction for six months. These side effects are interrupting the patient's daily life and ability to function at work and at home.' "
- Explain why you believe an amendment is necessary. For instance, you want the amendment because you worry your future health care or safety may be compromised by the incorrect information. In this case information about your experience with Topamirate may guide future treatment decisions, so it's important that the information in your record be correct.
Do you have questions about seeking an amendment to a medical record? Have you been through the process of requesting an amendment? What tips can you offer fellow Migraineurs? Please share your questions and/or tips in the comments.
How much has your migraine disease changed or evolved over time?