Medical Records
The medical record is the legal account of care. Understand what makes an entry defensible: date and time, author, objective findings, and clear documentation of what was done and why. Know the correction rules. Errors are corrected with a single line through the entry, the correction, the initials, and the date; never obliterate, white out, or delete. Late entries are added with the actual time of entry and a note that it is late.
Know the record's ownership and access rules: the provider or facility owns the physical record, but the patient has a right to access and obtain copies, generally within 30 days under HIPAA, with reasonable cost-based fees. Understand retention requirements (state law and payer rules set minimums, often several years past the last visit or past the age of majority for minors) and the rules for releasing records: authorization, subpoena, or a legal exception such as treatment, payment, or required reporting.
Traps: assuming a patient can demand deletion of an accurate entry (they cannot; they may request an amendment); confusing the legal health record with the designated record set; and forgetting that corrections must preserve the original entry.
Rule of thumb: if it is not documented, it did not happen; if it is documented, it must be accurate, attributable, and unaltered except by a visible correction.
Worked example: a medical assistant records the wrong blood pressure. The fix is a single strike-through, the correct value, initials, and date, not a rewritten page.