What recourse does a patient have in the event of accidentally false medical records?

Question

This story relates to my husband. He's 35 years old and had a vasectomy a few months ago. After the waiting period, he underwent the lab test to check that the procedure was successful. A few days after submitting his sample, he received an email from the urologist's office saying he had new information in his record (online patient portal).

To his excessive surprise, the new information was NOT the results of the lab test, but was in fact a record of a cancer diagnosis. Double testicular cancer, to be precise. After a bewildering and frantic hour, he was able to get confirmation from the urologist's office that no, he doesn't actually have testicular cancer. An orchiectomy (testicle removal) had also appeared on his record, although this was clearly false, if only due to the date on the record; the office confirmed that also didn't belong on his record. This was all an accident made by someone in the office, presumably.

A few weeks later, after many phone calls and two in-person visits to the office, the cancer diagnosis moved to a classification as a past condition, implying that it had been cured. The patient portal is handled by some other group, and the office claims they don't have the ability to remove records, hence the large volume of phone calls and trying to reach someone who does have that ability. Eventually, one cancer diagnosis was removed, but the other testicular cancer diagnosis and orchiectomy remain.

It seems clear that having this appear on his medical record will affect my husband negatively, at the very least in regards to insurance. And, as one can imagine, this has been a traumatic emotional experience for him. So here are my questions:

1. What, if any, law is being broken by the accidental addition of false information to his record?

2. What is the best way to actually enforce removal of the false information?

3. What kind of recompense can we seek, or expect to get, from this situation? (I.e., would it be reasonable to demand that the office reimburse him for the cost of his procedure?)

Answer 1

The relevant legal requirement to have accurate records is 45 CFR 156.526, where

An individual has the right to have a covered entity 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.

The request can be denied if the record is accurate and complete. A simple and pointed solution is to print that page and circle the section, in a letter requesting an amendment. A somewhat more costly and much more effective solution would be to get a lawyer to write a letter in legalese. It is hard to imagine that the provider would not comply. You will notice that they have 60 days to comply (+30 days extension if requested). If for some reason they insist on leaving the record as is, you have the right to insert rebuttal statements into the record (basically, prove that the record is false). There is no realistic hope of compensation for annoyance, but you can hope for a correction.