Patients wanting to redact OUD Dx in medical record

[drusso]

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Patient disagreed with mild OUD DX by DSMV and got second opinion. Now wanting complete redaction of medical record including all electronic transmissions.

What is your employer's policy on this?

 

[Ducttape]

my employer did not request or say anything, in the 3 cases where this was requested, over the past 7 years.

 

[drusso]

my employer did not request or say anything, in the 3 cases where this was requested, over the past 7 years.

Apparently, making a diagnosis is medical decision and redacting it is an employer decision. There's going to be *A LOT* of institutional variability on this one. The request our Center is dealing with is in dispute.

 

[101N]

Private forum.

 

[NOSfan]

Patient disagreed with mild OUD DX by DSMV and got second opinion. Now wanting complete redaction of medical record including all electronic transmissions.

What is your employer's policy on this?

Policy is simple, do not change medical records.

If you feel adding to the medical record is appropriate, make an addendum.

Cheers

 

[drusso]

Policy is simple, do not change medical records.

If you feel adding to the medical record is appropriate, make an addendum.

Cheers

I'm trying to draw out consensus/discussion on OUD DX as a QA activity versus Peer Review event versus X-number medical fraud.

 

[hyperalgesia]

I think most institutional EMRs don't allow you to change/redact records. My hospital IT will re-assign a note if it was erroneously written in the wrong pt's chart or something like that, not simply at pt's request.

 

[lobelsteve]

We do not reject our records. We can head an addendum. You're working diagnosis of opiate overuse disorder is appropriate. Just like a diagnosis of Lupus is appropriate if you need to rule it out and are ordering an ANA.

 

[drusso]

http://www.infograph.com/sites/default/files/whitepapers/Healthcare_Redaction_White_Paper.pdf

At minimum, special consideration for redaction should be given to the following categories of protected health
information:1 2
• Domestic violence
• Genetic information
• Mental health information (Psychotherapy notes cannot be
disclosed without explicit authorization.)
• Reproductive health
• HIV/AIDS
• Substance abuse (Federally funded substance-abuse
program information cannot be disclosed without explicit
authorization.)
• Information resulting from visits paid for out of pocket
(This pertains to disclosure to health insurance companies
only.)
• Information resulting from a visit paid for in cash, as
established in the HITECH Act
• Additional categories may be determined by state law

 

[NJPAIN]

In similar circumstances in the past I have told patients I cannot change what is written in the medical record as it is a legal document that represents MY findings/opinion at the time and not someone else's. I have told them they are welcome to dispute the diagnosis, findings, history, etc In writing and I will make that document part of the record.


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