June 2, 2002
How to Correct Your Medical Records
Caro Douglass and M.J. McKeown, MD
How do you go about disputing something in your medical record that is incorrect. And it is incorrect not because of transcription error, but because the doctor put down some things that are incorrect??
It should be sufficient for you to tell the physician involved and then ask to see a copy of the updated record. The entry should be identified as a correction of an incorrect entry.
If that does not seem to happen then you can send a certified letter with the suggested corrections and the reason for them to the physician and ask for a copy of the corrected record which once again should have the entry identified as a correction of a previous incorrect record.
I would certainly hope that any further action would not be necessary. I really hope that just asking nicely will solve the problem.
If you had to go to the length of the certified letter and there were no results then you can re-send the letter and identify it as one that is being re-sent and this time send a certified copy to the local or state medical society section on medical ethics.
If involving the physicians own professional oversight mechanisms still doesn't get the record changed then if you think the information is damaging to you in some way if it becomes known or used by some insurance company or etc you can hire a lawyer and become involved in a real adversarial situation in an attempt to change the information. I would hope it won't get this far since I expect it will be expensive for you.
Try just asking nicely and deal with the physician directly not some office staff. The old adage that one can get more flies with honey than with vinegar is true.