Do You Really Have All of The Medical Records?

A complete and comprehensive medical record can be crucial evidence in any medical-related litigation claim. It is too common not to be provided with all the medical records even when requested. As an attorney, you may think you have all the records, but being wrong could cost you your case. Medical records are equally crucial for both sides of litigation. Finding that can affect your case include fraudulent concealment, spoilation of medical records, patient noncompliance, incorrect medication dosages or evidence of drug abuse, inaccurate diagnosis, inappropriate therapies, damages that are present, and adherence or nonadherence to standards of care. Below you will find an easy reference guide to help you determine if you have all the records needed for your case.  

Records Attorneys should have for hospital visits, and inpatient hospital stays:  

• ER Records (Should include all items below)  
• Face Sheet (Contains identifying information)  
• Discharge Summary  
• History and Physical (H&P) with 5 components: history, review of systems physical exam, the assessment and plan of care  
• Physician Notes, ARNP Notes, and PA Notes  
• Imaging Reports  
• Imaging Films  
• Lab records  
• Transfusion Records  
• MAR Medication Administration Records  
• Data Flowsheet   
• Nursing Progress Notes and Assessments and Care Plan  
• Consult Notes (nutrition, PT, OT, Speech, Social Work, etc.)  
• OR Records (Consent, Preop nursing notes, intraoperative notes, Time-out, site markings, anesthesia records, operative and procedure reports, pathology report, PACU records)  

Medical information not part of the patient's medical record:  

• Facility management records (staffing schedules, policies and procedures, incident reports, etc.)  
• Electronic communication  
• Patient portals  
• Hospital department maintenance logs  
• Electronic Fetal Monitoring (EFM) *may require the mother's records to obtain   
• Photographs  
• Videotapes  
• EMS reports  
• Death certificate  
• Autopsy report  
• Pathology specimen records  
• Medical equipment records  

Outpatient records to obtain:  

• Physician Office  
• Pharmacy  
• Chiropractic  
• Alternative Medicine  
• Home care  
• Rehab Services  
• Military Health  
• Employee Heath  
• Hospice   
• Alcohol, Drug Treatment, Mental Health, HIV related   
• Long Term Care  
• Corrections  

Other Records Containing Medical Information:  

• 911 Transcripts  
• Medical Billing  
• Patient incident reports  
• Work Site Injury Reports  
• Police Accident Reports  
• School Records  
• Social Media Records  
• Disability Records (SSI, Worker's Compensation, etc.)  

Portside Legal Nurse Consulting can assess your records for your case and let you know what is missing. Portside can be reached via our website at www.portsidelegalnurse.com or by email at [email protected].