Patient-initiated electronic health record amendment requests

Area of Science:

• Health Informatics
• Patient Access to Records
• Medical Documentation

Background:

• Patient access to medical records offers benefits like error identification and correction.
• Patient-initiated requests for changes to medical records are termed 'amendment requests'.
• Limited understanding exists regarding the characteristics and outcomes of patient amendment requests.

Purpose of the Study:

• To analyze the nature of patient-initiated amendment requests.
• To determine the outcomes of these amendment requests.
• To explore patient motivations behind record amendments.

Main Methods:

• Qualitative content analysis of patient amendment requests over seven years.
• Categorization of requests by clinical area, patient motivation, and outcome.
• Analysis of 818 distinct requests from 181 patients.

Main Results:

• The majority of requests (77.8%) aimed to correct inaccurate information.
• Nearly half (49.7%) of all amendment requests were approved.
• A small percentage (6.6%) sought removal of valid information, with 27.8% of these approved.

Conclusions:

• Low patient amendment request rates may stem from insufficient awareness of patient rights.
• Informing patients about amendment processes is crucial for effectiveness.
• Enhancing patient access can improve medical record accuracy, but requires careful consideration.