Correction to a Record of Personal Health Information (by a patient)

Policy: Correction to Personal Health Information (Patient)

An individual having been granted access to a record of personal health information (health record) about the individual in the custody or under the control of a health information custodian may make an informal request (oral) or a request in writing a correction to that record, if the individual believes the record is inaccurate or incomplete for the purposes the record was collected or used.

The following are the obligations placed on Health Records when responding to an individual’s request for access to a record of his or her personal health information.

Request Process: Patient

• If the patient makes an informal (oral) or written request to the health information custodian who has custody or control of the individual’s record of personal health information for a correction to his or record, and
• Gives the custodian the information necessary to enable the custodian to correct the record.

Time Frame

Health Records must:

• Respond to the request within 30 days from the date of receipt of the request to a maximum of 60 days after receiving the request if an extension is required.
• Provide the individual with a written notice if extending the time frame, setting out the length and the reasons for the extension.
• Be deemed non-compliant or have refused the request if the custodian does not respond within the time limit or before the extension expires.

Approval Process

Health Records must:

• Determine the validity of the requested correction by consulting with the persons or professionals responsible for the entry in the record if required, or examining the information that the individual provides to the custodian.
• Assess whether the request is frivolous, vexatious or made in bad faith.

Correction Granted

The “Author” of incorrect or incomplete information will:

• Make the correction in the record by: striking out the incorrect information in a way that does not obliterate it; or if not possible;
• Label the information as incorrect, advise Health Records of the change and send the record to Health Records. Health Records will sever the incorrect information from the record, and store it separately, while maintaining a link in the record to trace the incorrect information;
• If it’s not possible to correct the record (i.e. an electronic record) then direct a person who accesses the record to the amended record with the correct information.

Notice of Corrected Record

Health Records must:

• Give notice to the individual of what was done in writing.
• Give written notice to persons to whom the custodian has disclosed the information with respect to the correction unless the correction cannot reasonably be expected to have an effect on the ongoing provision of health care or other benefits to the individual.

Reasons for Refusing To Correct Personal Health Information

The hospital is not required to correct a record:

• If it is a professional opinion or observation about a patient made in good faith.
• If it was not made by an employee or agent of the hospital.
• Where there is insufficient knowledge, expertise and authority to correct the record.
• Where there is no ability to validate the new information provided.
• Where the patient has been unable to demonstrate that the record is incorrect or incomplete or has not given you the information to make the correction.

Correction Refused

Health Records must:

• Notify the individual in writing that the request for correction has been denied and the reasons for the refusal.
• Inform the individual of his/her right to attach a “statement of disagreement” that sets out the corrections that were requested but refused.
• Disclose the “statement of disagreement” whenever the custodian discloses the information to which the statement relates.
• Make all reasonable efforts to disclose the “statement of disagreement” to any person who had received information to which the statement relates.
• Inform the individual that he/she is entitled to make a complaint about the refusal to the “Commissioner”.