Community Grievance Decision Digest

RECORDS, CORRECTION OF INFORMATION IN

The decision summaries regarding this law may be found in the document:
Community Grievance Decision Digest: Decisions. (PDF, 512KB)

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."

ss. 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:

1. 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 ss. 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)

2. 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: June 18, 2009