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Old May 04, 2011, 02:55 PM
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Beholden Beholden is offline
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Member Since: Jan 2009
Location: In my watercolor paints and garden a lot.
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"I got a copy of it, read it, and found inaccuracies.

I discussed those inaccuracies with the Psychologist and the Psychologist told me he was willing to make the appropriate modifications."

If what you found were indeed 'inaccuracies', your P should correct them, not change them. If there is a mistake, it should be corrected.

But to out and out 'alter' the clinical record just to sooth you, that would be wrong and illegal.

imo:

When I worked in medical records for dentist, chiropractor, family practice doc, and cancer specialists, all statements written in the client's record had to be initialed, dated, and the doc had to see the entry of all who made them.

If it is the 'evaluation' that he wrote that had something not accurate, or especially if there is nothing in the clinical record to back it up, that may be a different sort of situation.

The clinical record is a legal document. If it isn't in there, it 'didn't happen'. He can make an amendment or what ever the correct word is to your record.