The Chart Note Edited After the Fact
Marcus is a physical therapist at an outpatient clinic. On Monday he writes a progress note for a patient with shoulder pain. On Wednesday, the patient reports a fall at home and new tingling in the hand. Marcus realizes that his Monday note omitted the patient's report of numbness and instead said “no neurological symptoms.” He opens the Monday note, changes the sentence to include numbness, saves over the original, and does not add an addendum, initials, or date. The patient later asks for a copy of the record. The office manager says they can withhold the note because “it might look bad in a lawsuit.” The patient's adult daughter then calls and asks for the records; the patient has not signed an authorization.
1. Evaluate Marcus's correction of the Monday note. What should he have done?
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Marcus should not have overwritten the original. The record must be accurate and trustworthy. If he omitted relevant information, the proper method is a late entry or addendum: date and time it, identify it as an addendum, initial it, and explain the source of the new information-here, the patient's report on Wednesday. The original note should remain visible. Overwriting creates the appearance of falsification and can support a Board complaint for unprofessional conduct, regardless of whether Marcus intended to deceive. The new neurological symptom also required a prompt reassessment and documentation of his clinical response. He should now prepare a clear addendum describing the correction and the patient's new symptoms, and not alter the original further.
2. Must the clinic release the record to the patient? Can it withhold the note because litigation is possible?
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Generally, the patient has a right to access his own record. HIPAA gives patients a right to inspect and obtain a copy of their protected health information, subject to limited exceptions, and Oregon law may add requirements. A provider cannot withhold records merely because they might be embarrassing or unfavorable in a lawsuit. The clinic may charge a reasonable, permitted fee and should follow its authorization and verification procedures. If a specific legal exception applies, the clinic should consult counsel and provide a written explanation. The office manager's “might look bad” rationale is not a lawful basis to deny access.
3. Can the clinic give the records to the patient's adult daughter?
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Not automatically. The daughter is an adult and is not the patient's personal representative merely because she is family. HIPAA permits certain disclosures to family involved in care only in limited circumstances, such as when the patient agrees, has the opportunity to object, or in an emergency. Without the patient's authorization or legal authority, the clinic should decline and offer to obtain a signed authorization. If the patient lacks capacity, a guardian or health care representative may be appropriate. Releasing records to the daughter without authority would be a confidentiality breach.