the Medical Records
Obtaining a copy of the complete medical
records is more difficult than it sounds. However, without
an accurate copy of these vital records, a patient has
virtually no chance of proving a medical malpractice
In trying to obtain a complete an accurate
copy of the medical chart, there are a couple of important
facts to keep in mind. First, a patient must make a
written request to the involved health care provider
in order to receive a copy of their records. Since March,
2003, these written requests must be made in a specific
With the exception of care rendered to
a patient in the hospital, each health care provider
keeps separate records on the patient for the care they
rendered to the patient. All records from a patient's
hospitalization are kept by the medical records department
of the hospital. In order to obtain a copy of these
records, a written request must be made through the
medical records department.
When making a request for such hospital
records, it is important for the patient or family member
to review the original chart first. This way, the copies
can be checked to make sure that all of the records
were in fact copied.
When making a request for records from
either the hospital or a physician's office, attention
should not be called to the fact that the records are
being sought for a potential medical malpractice claim.
Most patients will tell the provider that the records
are being sought for a second opinion physician or to
make sure that future medical providers are accurately
informed about past medical history.
When a patient sees a physician in the
physician's office and not the hospital, the records
must be obtained from the physician's office. The hospital
does not keep physician office notes or records. The
physicians also usually do not keep any part of the
hospital records in their chart, (with the exception
of the operative report or other few pages). Thus, a
patient must get records from both locations.
Most hospitals and physician offices
become keenly aware of requests for patient records
that are made by an attorney. In fact, some hospitals
have a policy of routing attorney requests for records
through their risk management department so that a risk
manager can review the records first.
For these reasons, and the potential fear
of record alteration or loss of records, it is very
important that the first request for records come from
the patient or his family. Later, after the claim has
been filed, the attorney can get a certified copy of
the records which can then be compared to the ones obtained
by the patient.
Keep in mind that certain types of records
are not kept in the formal medical record and must be
specifically requested separately. For instance, the
fetal heart monitor strips used to monitor babies in
the womb are usually not part of the formal record and
must be requested separately. These records are often
the critical records to detemine whether malpractice
occurred. They are also the first records to get lost
Finally, it should be mentioned that records
are not always immediately available. Hospital records
generally will not be made available until approximately
30 days after discharge.