Medical Records 101, Lesson 1
Tips for Requesting and Reviewing Medical Records
Janabeth F. Taylor
Whether your practice involves medical malpractice,
personal injury, toxic tort or even family law you will at some point in time have the need to
request medical records.
Most states have a section in the Rules of Civil Procedure covering specifics of request
format, time to respond and charges for medical billing. Be sure to check your state code prior to
preparing a request for medical records.
Below are some tips for paralegals and attorneys who will need medical records in order to
substantiate a claim and answer discovery through production of medical records.
•
Interview the client to obtain as complete a medical history as possible. If they have
billing records copy and retain those, as they will contain important contact information for health
care providers.
•
Remember billing and medical records may not be maintained at the same facility and a
separate request for each is needed.
•
Obtain the pharmacy billing records prior to and subsequent to the incident in question. Have
the potential client bring these for the initial interview. They will contain a thumbnail sketch of
the patient’s medical care prior to the incident in question, identify prescribing/healthcare
providers as well as document medication taken (such as pain medication) to aid in supporting
damages.
•
Many medical records, especially nursing documents are multiple pages with dates, signatures
only on one page. It is suggested you request multiple pages be stapled in order, this is crucial
for establishing dates/times and providers in a chronological order.
•
Often treatment and medications records are double-sided with initials/signatures and
comments on the opposite side. Be sure to request double sided copies, or if single sided copies,
request they be stapled together. These records may contain crucial information in a case.
•
As in any case of medical negligence or malpractice, the medical records are extremely
important in proving the facts showing negligence, causation, and damages.
•
Obtain ALL of the nursing home, clinic, urgent care, emergency room, ambulance, visiting
nurse, occupational therapy, speech therapy, physical therapy and respiratory therapy
records and ALL doctor and hospital records.
•
Sometimes urgent care, ambulatory care clinics,
emergency rooms, ambulances, nursing and various
therapy services, etc., are independent contractors. Establish with the hospital or institution what
care is provided by independent contractors and where to address medical records requests to ensure
you are ordering ALL of the available medical records.
•
Even if all of the available medical records are not part of the alleged incident and hence
are not subject to the medical review, they should still be obtained as reference material.
•
The records just prior to and after an alleged incident are especially important in providing
documentation as to the person’s medical condition, the extent of the alleged injuries as well as
an indication of any probable long-lasting complications that may now exist.
•
Key Point: Information
is often obtained from seemingly obscure records, hence the need for ALL of the medical records.
Janabeth F. Taylor, R.N., R.N.C. has a degree in Nursing from Oklahoma
State University and Litigation Paralegal Certificate
from the University of Oklahoma Law Center. She was a nursing instructor for ten years and has been
a medical legal consultant since 1990. Ms. Taylor is currently President/Owner of Attorney’s
Medical Services, Inc. in Corpus Christi, TX.
In 2002 she was named the Association of Trial Lawyers of America’s Paralegal of the Year.
She provides litigation support for attorneys across the United States and specializes in case
reviews and Internet information resources. Her website is http://www.attorneysmedicalservices.com
and her e-mail address is jana@attorneysmedicalservices.com
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