Community Grievance Decision Digest
RECORDS, CORRECTION OF INFORMATION IN
THE LAW:
"A subject individual,
or the parent, guardian or person in the place of a parent of a minor, or
the guardian of an incompetent may, after having gained access to
treatment records, challenge the accuracy,
completeness, timeliness, or relevance of factual information in his
or her treatment records and request
in writing that the facility maintaining the record correct
the challenged information. such
request shall be granted or denied
within 30 days by the director of the treatment facility, the director
of the county department under s. 51.42 or 51.437, or the secretary
depending upon which person has custody of the record.
Reasons for denial of the requested changes shall be given by the
responsible officer and the individual shall be informed of any applicable
grievance procedure or court review procedure.
If the request is denied, the individual, parent, guardian or
person in the place of a parent shall be allowed to insert
into the record a statement correcting or amending the information at
issue. The statement shall
become a part of the record and shall be released whenever the information
at issue is released."
§ 51.30(4)(f), Wis. Stats. [Emphasis
added.]
"(a) Correction of
factual information in treatment records may
be requested by persons authorized under s. 51.30(4)(f), Stats., or by
an attorney representing any of those persons.
Any requests, corrections or denial of corrections shall be in
accordance with s. 51.30(4)(f), Stats., and this section.
(b) A written request
shall specify the information to be
corrected and the reason for correction and shall be entered as part
of the treatment record until the requested correction is made or until
the requester asks that the request be removed from the record.
(c) During the period that the request is being reviewed, any release of
the challenged information shall include a copy of the information change
request.
(d) If the request is granted,
the treatment record shall be immediately
corrected in accordance with the request.
Challenged information that is determined to be completely false,
irrelevant or untimely shall be
marked through and specified as
incorrect.
(e) If the request is granted,
notice of the correction shall be sent to the person who made the
request and, upon his or her request, to any specified past recipient of
the incorrect information.
(f) If investigation casts
doubt upon the accuracy, timeliness or relevance of the challenged
information, but a clear
determination cannot be made, the responsible officer shall set forth in
writing his or her doubts and both the challenge and the expression of
doubt shall become part of the
record and shall be included whenever the questionable information is
released.
(g) If the request is denied,
the denial shall be made in writing
and shall include notice to the
person that he or she has a right to insert
a statement in the record disputing the accuracy or completeness of
the challenged information included in the record.
(h) Statements in a
treatment record which render a diagnosis are deemed to be judgments based on professional expertise and are not
open to challenge."
HFS 92.05(5), Wis. Admin. Code
[Emphasis added.]
[NOTE: The federal Health
Information Portability and Accountability Act of 1996 (HIPAA)
went into effect April 14, 2003. That
act contains provisions concerning correction of records that affect or
may supercede state law. Stage
3 and 4 grievance decisions issued concerning issues that arose prior to
that date do not take into account HIPAA standards. The HIPAA standards
are:
"(1)...
An individual has the right to have a [service provider] amend
protected health information or a record
about the individual in a designated record set for as long as the
protected health information is maintained in the designated record set.
(2) ...A
[facility] may deny an
individual's request for amendment,
if it determines that the protected health information or record that is
the subject of the request:
(i)
Was not created by the [service provider], unless the individual
provides a reasonable basis to believe that the originator of protected
health information is no longer available to act on the requested
amendment;
(ii) Is
not part of the designated record
set;
(iii)
Would not be available for inspection
under [other provisions]; or
(iv)
Is accurate and complete."
45 CFR 164.526(a) [Emphasis added.]
DECISIONS:
-
A client objected
to an entry in her chart which raised the possibility that the
client was stalking her
therapist. She was
informed of her right to enter a correction of information into the treatment record
per § 51.30(4)(f), Stats. She did enter an addendum in the record and
it is now attached to the reference about possible stalking concerns
and will be released whenever the related record is released.
This was the appropriate remedy for her objection.
(Level III Grievance Decision in Case No. 04-SGE-07, affirmed
at Level IV on 8/15/05)
-
An
outpatient client disagreed
with her therapist
assigning her an Axis II Borderline Personality Disorder diagnosis.
A diagnosis is ultimately a professional opinion and
given “due deference”. However,
the professional opinion of the therapist did not take into account
the physiological factors that the client later became aware of,
post-therapy. It was recommended
that she submit a clarification
of her treatment record that included her experiences and the medical
information from her physician.
(Level III Grievance Decision in Case No. 05-SGE-12 on 5/16/06)
Last Updated: November 08, 2006 |
