Can you amend a patient’s chart after it was requested for review?
A phone call from a client today reminded me of a frequent question I still receive. I was told that an attorney requested a copy of a patient’s chart. Can she/he change their notes? The short answer is no. The time to make sure the notes were accurate were at the time the notes were made. Electronic Medical Records have a log that will record any changes made. It is allowed to amend your notes to correct any inaccuracy. Amending a note (clearly labeled as such, with a date and signature) is allowed. Waiting to do so until there is a chart request damages credibility. Review your charts soon after a note is made. Even ethically amending a chart months or years later, is harder to explain.
Larry Kobak, Esq.
Lawrence F. Kobak, Esq.
ATTORNEYS AT LAW