David A Hanauer1, Rebecca Preib2, Kai Zheng3, Sung W Choi4. 1. Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan, USA School of Information, University of Michigan, Ann Arbor, Michigan, USA. 2. College of Literature, Science, and the Arts, University of Michigan, Ann Arbor, Michigan, USA. 3. School of Information, University of Michigan, Ann Arbor, Michigan, USA Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, Michigan, USA. 4. Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan, USA.
Abstract
BACKGROUND AND OBJECTIVE: Providing patients access to their medical records offers many potential benefits including identification and correction of errors. The process by which patients ask for changes to be made to their records is called an 'amendment request'. Little is known about the nature of such amendment requests and whether they result in modifications to the chart. METHODS: We conducted a qualitative content analysis of all patient-initiated amendment requests that our institution received over a 7-year period. Recurring themes were identified along three analytic dimensions: (1) clinical/documentation area, (2) patient motivation for making the request, and (3) outcome of the request. RESULTS: The dataset consisted of 818 distinct requests submitted by 181 patients. The majority of these requests (n=636, 77.8%) were made to rectify incorrect information and 49.7% of all requests were ultimately approved. In 6.6% of the requests, patients wanted valid information removed from their record, 27.8% of which were approved. Among all of the patients requesting a copy of their chart, only a very small percentage (approximately 0.2%) submitted an amendment request. CONCLUSIONS: The low number of amendment requests may be due to inadequate awareness by patients about how to make changes to their records. To make this approach effective, it will be important to inform patients of their right to view and amend records and about the process for doing so. Increasing patient access to medical records could encourage patient participation in improving the accuracy of medical records; however, caution should be used. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
BACKGROUND AND OBJECTIVE: Providing patients access to their medical records offers many potential benefits including identification and correction of errors. The process by which patients ask for changes to be made to their records is called an 'amendment request'. Little is known about the nature of such amendment requests and whether they result in modifications to the chart. METHODS: We conducted a qualitative content analysis of all patient-initiated amendment requests that our institution received over a 7-year period. Recurring themes were identified along three analytic dimensions: (1) clinical/documentation area, (2) patient motivation for making the request, and (3) outcome of the request. RESULTS: The dataset consisted of 818 distinct requests submitted by 181 patients. The majority of these requests (n=636, 77.8%) were made to rectify incorrect information and 49.7% of all requests were ultimately approved. In 6.6% of the requests, patients wanted valid information removed from their record, 27.8% of which were approved. Among all of the patients requesting a copy of their chart, only a very small percentage (approximately 0.2%) submitted an amendment request. CONCLUSIONS: The low number of amendment requests may be due to inadequate awareness by patients about how to make changes to their records. To make this approach effective, it will be important to inform patients of their right to view and amend records and about the process for doing so. Increasing patient access to medical records could encourage patient participation in improving the accuracy of medical records; however, caution should be used. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
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