HIPAA Case Study – Transcription Error

Posted by Donna Craig in Feb, 2018

A patient was admitted to the hospital for a medical condition that required surgery.  The patient had a significant past medical history for hyperlipidemia, which is abbreviated as “HLD”.  When the admitting physician dictated the patient’s medical history, including his history of hyperlipidemia, the transcriptionist interpreted the dictation of “HLD” as “HIV”.  This transcription error was discovered when the surgeon advised the patient that special precautions were needed in order to perform surgery in light of his history of HIV.  While the hospital freely admitted to the transcription error, such a mistake could have profound consequences for the patient’s future medical care.

The Health Law Center was retained to correct the mistake and ensure that future health care providers would be alerted to the error in the hospital’s medical record.  Correcting this error required both the skills of a health care attorney who has in depth knowledge of HIPAA and the knowledge of how to navigate the hospital bureaucracy in order to reach the appropriate administrator to resolve this matter. We entered into negotiations to amend the hospital’s medical record as well as address how the hospital would respond to future health care providers’ requests for a copy of the medical record.