Getting 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 case.

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 format.

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 or misplaced.

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.