A request to amend a medical record can identify a disagreement, but it does not establish what occurred, medical causation, responsibility, or a claim outcome.

Identify the exact record entry

  • Provider, date of service, record type, page or portal location, and the exact information believed to be incomplete or inaccurate
  • A concise explanation of the requested correction, any document that supports the request, and a copy of the original record kept unchanged
  • The date the request was sent, method used, response received, and any amendment or statement of disagreement provided
  • Questions about diagnosis, care, fault, or a claim kept separate from the request itself

Use current consumer guidance

The North Carolina Medical Board’s Smart Patient Toolkit on amending medical records describes the record-amendment process and possible responses. Provider-specific procedures and the nature of a request can affect what happens next.

Questions about a North Carolina medical-malpractice claim require a fact-specific review.

Source