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CANHR Advocate Did You Know Articles

You Have a Right to Clear up Inaccuracies in your Medical Record

According to California Health and Safety Code §123111, patients have the right to clear up inaccuracies in their health and medical records. If during review of your records you find items or statements that are incorrect or incomplete, you have the right to prepare and present an addendum of up to 250 words per item. You must clearly state in writing that you wish to have the addendum added to your medical record. The health care provider must attach the addendum to your records and include the addendum whenever it makes a disclosure of the allegedly incomplete or incorrect portion of your records to any third party.

Nursing home residents and their representatives have the right to access and review all their records within 24 hours of an oral or written request (excluding weekends and holidays). Title 42, Code of Federal Regulations, §483.10(b)(2).

It is a good idea to periodically review your records to see if there are any problems. Look to see what care and treatments are documented and how they compare with reality. Also check to see if your care plan reflects your needs and discussions about how to address them. If not, correct it. If you or a loved one were subjected to neglect, abuse or mistreatment, it is particularly important to examine the records to see how well it is documented. Take advantage of the opportunity the law affords to correct misinformation that often appears in medical records.