How to Change Incorrect Medical History Records

A patient can correct his medical record in one of two ways: the SLIDE technique and an addendum. The SLIDE technique is used when correcting mistakes right away. An addendum provides a correction or other pertinent information to a previous visit's entry.



Everyone should monitor his medical record, just as he would his credit report, to ensure that mistakes are corrected immediately. If the medical record is incorrect, the insurance company will most likely also have incorrect information.

Instructions

SLIDE Technique for Corrections

• 1

  Ask the medical assistant in the physician's office to correct your medical record using the SLIDE technique. This technique is used to correct mistakes in the medical record immediately after they happen. It's used because correction fluid or correction tape is not permitted to be used on any medical record. The first step of the SLIDE technique, the "SL," is to draw a single line through the wrong information.

• 2

  Initial the entry so others will know who made the correction.

• 3

  Date the entry with the current date.

• 4

  List the reason for the correction or error.

Correction by Addendum

• 5

  Request a copy of your medical record. Doctors are required to give patients a copy of their medical record if you ask for it. They may charge a fee. Review the medical record for errors. If you find an error, you can initiate a request for correction with the physician's office where the original record was generated.

• 6

  Speak with a medical assistant in the physician's office about the correction that you believe is needed in your medical history. A medical assistant is the equivalent of a medical secretary. He handles administrative paperwork and performs some clinical duties. The medical assistant may have to speak with the doctor about the information in question.

• 7

  File an addendum with the medical assistant once she has verified all information with the doctor. This will consist of a note added to the original medical record labeled "addendum." The addendum should have the date, time and initials of the medical assistant, along with the reason for the correction and what the correct information is. The patient may also be asked to sign the addendum.