The Client Who Wants Her Records - and Wants Them Changed
Daniel is an OT at a Mat-Su clinic treating a 34-year-old woman for a work-related wrist injury. After a disagreement about her return-to-work restrictions, she demands a copy of her entire record, including the OT's progress notes and a consult note from a physiatrist. She also asks Daniel to "remove the part where I got upset" from a progress note, saying it makes her look bad and could hurt her workers' compensation claim. The clinic owner tells Daniel to "stall" the request until after the claim is decided. Daniel's note accurately documents that the client raised her voice and declined a home exercise program. The client has not paid her last two invoices.
1. Must Daniel provide the records? What about the physiatrist's consult note?
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The client has a right to access her own health record. The clinic should follow Alaska law and clinic policy on patient access, including timelines and any permitted fees for copies. The OT's own progress notes are part of the record and generally must be produced. The physiatrist's consult note is another provider's record; the clinic should release what it legitimately holds as part of the treatment record, but Daniel should not independently alter or withhold another provider's documentation. Unpaid invoices are not a lawful basis to deny access to records in most frameworks; Daniel should not use billing as leverage without confirming the specific rule.
2. Should Daniel alter the progress note at the client's request? How should he respond to the "stall" instruction?
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No. The note is an accurate contemporaneous record; removing true content falsifies the record. The proper mechanism is an addendum: Daniel may add a late entry noting the client's perspective or a correction of fact, clearly dated and attributed, without deleting the original. He should explain this to the client. As for the owner's instruction to stall: delaying a legitimate access request to influence a legal claim is improper and may violate record-access rules. Daniel should follow the lawful timeline, document the request and his response, and escalate the conflict rather than participate in delay.