[impromt]

After I was done with therapy the Psychologist wrote a psychological evaluation.

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.

I thanked him for his willingness to correct my report, but then I read somewhere that it is actually illegal to modify a patient's record.

Assuming that's true, did the psychologist do something illegal or probably lie to me in order to soothe me?

[SpiritRunner]

maybe with your permission, it is not illegal to modify it, if there are inaccuracies that should be modified and not left as they are?
I don't know all the rules, and legalities, but seems reasonable enough to think that modifications could be made with your permission or at your request!

[SoupDragon]

I wouldn't see it as illegal to make amendments if there were any inaccuracies, indeed it would be more wrong if inaccurate information was held on you. It wouldn't be appropriate to alter clinical records taken at the time of an assessment however.

[Beholden]

"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.

[Perna]

Originally Posted by impromt

After I was done with therapy the Psychologist wrote a psychological evaluation.

I got a copy of it, read it, and found inaccuracies.

I don't think it is ever illegal to change one's own writing/evaluation. There's nothing "formal" there. It's mostly the psychologist's point of view of your therapy/evaluation. If they say they will change the statement that you have two heads, to one I imagine they will but anyone else looking at you in the future is going to see you only have one head? That's all that counts. If you don't like your record overall, it's covered by HIPAA privacy and you just refuse to share it (or don't mention that it exists).

[dizgirl2011]

Originally Posted by Improving

I don't see this as modifying the record of your treatment. It's not a historical record, it's a report I think? And the practitioner wouldn't be changing any true facts; he would be amending the report to reflect the true facts.

This is pretty much my feeling on it to, it wasn't the changing of documents held on what had happened to you during your therapy, it was an evaluation report written because you had finished ( I am assuming). As you were also sent a copy it means you were made aware of the report and the only reason that it was being amended was at your request, there's nothing illegal here.

If it was a case were you perhaps were taking a case against your treatment or something and found that information in your file had been altered in a way to cover up some wrong doing then it would probably be illegal and need investigating as that would be covering up malpractice.

all the best
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