If an Ultrasound Obstetrical exam is started, completed and closed, can the closed report contained in that exam be modified, altered or changed without explanation, footnote or amendment to that report? If not, can you provide me with the paragraph that supports that position?
Country relating to Question: United StatesState (if USA): CaliforniaWhat have you tried so far?: Initial inquiry
Thank you for the post, I am happy to assist you by answering your questions. Is it that the information in your medical record is incorrect?
In many cases yes, but sometimes the physician wants to reopen a closed exam just for validation and remeasurment purposes done by the technition or the one who perfomed the exam.
ok, and you mean without a patient request or dispute of the findings in the medical record?
Yes, without a patient request or dispute of the findings in the medical record as represented to the patient?
Thank you, XXXXX XXXXX as there is not a fraudulent intent, a physician or licensee (or agent acting on behalf of the same) is free to correct a medical record. As a practical matter, it would be extremely inefficient not to permit correction. Please let me know if you have any follow up questions.
So if there are no fraudulent intentions, but occassional carelessness on behalf of the clinicians, it is practical, responsible and the medical obligaton for practioners to make the necessary, accurate corrections to a closed report. Is that correct?
Yes, that is correct. As a practical matter, consider how inefficient our healthcare system would be if this was not the case.
Can you send me an email of this exchange including all questions and answers to XXXXX@XXXXXX.XXX with your expert comments and your identificaton information. You will not be contacted...just meant to be a credible opinion. Thank you!--Bruce
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