Medical Records and Malpractice: How Documentation Can Make or Break Your Case

November 22, 2023
Medical Records and Malpractice: How Documentation Can Make or Break Your Case

In the complex world of medical malpractice, thorough evidence and documentation are key. For those seeking justice and redress, medical records often play a pivotal role in substantiating claims and demonstrating malpractice. As with any legal pursuit, it’s crucial to know what to gather, how to gather it, and how to effectively present this evidence. This guide, presented by Matzus Law, LLC, delves deep into the importance of medical records in a malpractice claim.

Why Medical Records Are Important

Medical records serve as the official documentation of a patient’s healthcare history, their diagnoses, prescribed treatments, and the progression of their medical conditions. For those pursuing a malpractice case, these records become vital evidence for several reasons:

  • Objective Evidence: Unlike testimonies, which can be subjective, medical records are objective and unbiased accounts of medical events.
  • Timeline Establishment: They help establish a clear timeline of events, showing when a medical professional saw the patient, what treatments were given, and how the patient’s condition evolved over time.
  • Standard of Care: Medical records can demonstrate whether the care provided met the accepted medical standard. Deviations can point towards negligence.

How to Obtain Your Medical Records

Obtaining your medical records is essential for a variety of reasons, whether you’re switching healthcare providers, keeping a personal copy, or need them for a legal case. Here’s a step-by-step guide on how to obtain your medical records:

  • Know Your Rights: In the U.S., the Health Insurance Portability and Accountability Act (HIPAA) gives patients the right to access and obtain a copy of their medical records from most health providers, with a few exceptions. Similar rights are granted to patients in many other countries.
  • Identify the Correct Provider or Department: The first step is to determine where your medical records are stored. This might be with your doctor’s office, a hospital’s records department, or a specific medical records department within a healthcare system.
  • Submit a Written Request: Most institutions require a formal, written request to release medical records. Some may provide their own form for you to fill out. The request should include:
    • Your full name (including any previous names)
    • Date of birth
    • Social security number (if applicable)
    • Address and phone number
    • Specific details of the information you’re requesting (e.g., the date range of the records, types of records like X-rays or lab results)
  • Indicate Delivery Preference: You can usually choose how you’d like to receive the records, whether it’s in paper form, through electronic media like a CD, or via secure email.
  • Be Prepared for Fees: While you have a right to your records, institutions might charge a fee for compiling, copying, and mailing them. However, they should inform you of any fees beforehand, and in some cases, they can be waived or reduced, especially if you can prove financial hardship
  • Wait for a Response: Providers typically have up to 30 days to respond to your request under HIPAA, although many will do so sooner. If they need more time, they should notify you of the delay and provide a reason.
  • Review the Records for Accuracy: Once you receive your records, go through them to ensure they are complete and accurate. If you notice any discrepancies or errors, you can request a correction. However, the healthcare provider can deny this request if they believe the record is accurate or if they did not create the information.
  • Consider Storing Them Safely: Given the sensitive information in medical records, it’s important to store them securely, whether it’s in a safe deposit box or using encrypted electronic storage.
  • Know Who to Contact for Issues: If you believe a healthcare provider is unjustly denying your request for records or if you encounter other issues, you can file a complaint with the U.S. Department of Health and Human Services’ Office for Civil Rights or your local patient advocacy group.

Remember, medical records are a comprehensive account of your health history, and having access to them ensures continuity of care and can be crucial in situations like medical malpractice cases.

Pitfalls to Avoid When Using Medical Records in a Case

Medical records are vital pieces of evidence in malpractice cases, as they provide an official account of a patient’s medical history, treatments received, and any interactions with healthcare professionals. However, utilizing them in a legal scenario requires careful attention. Here are some pitfalls to avoid when using medical records in a case:

  • Incomplete Records: One of the most common pitfalls is assuming that all the medical records received from a provider are complete. Always cross-reference the records with personal notes, recollections, and any other medical documentation to ensure no details are missing.
  • Misunderstanding Medical Terminology: Medical records can be filled with complex jargon and shorthand. Misinterpreting or misunderstanding these can weaken the case. It’s always advisable to have a medical professional review and interpret the records.
  • Over-reliance on Records Alone: Medical records, while valuable, are just one piece of the puzzle. Relying solely on them without considering other forms of evidence, such as expert testimony, can lead to an incomplete portrayal of events.
  • Failing to Protect Patient Privacy: Not ensuring the confidentiality of medical records can result in unintended breaches of privacy. Only authorized individuals should access these records, and any disclosures must follow the guidelines set by laws like HIPAA.
  • Neglecting to Highlight Relevant Details: Amidst the plethora of information, some crucial details can be overlooked. It’s essential to thoroughly review and highlight relevant information that directly impacts the case.
  • Using Unauthenticated Records: Just because a document appears to be a legitimate medical record doesn’t mean it will be admissible in court. Ensure all records are authenticated, ideally by the original author or the institution that issued them.
  • Not Challenging Errors: Sometimes, medical records may contain errors. Accepting these records without challenge can harm the case. If there’s a belief that the records have inaccuracies, they should be addressed and, if possible, corrected.
  • Delay in Acquisition: Waiting too long to request or review medical records can lead to unnecessary delays, potentially hindering the case. Always start the process as soon as possible.
  • Not Using Expert Witnesses: Especially in complex cases, expert witnesses can help interpret and provide context for medical records. They can clarify procedures, terminology, and the standard of care, giving weight to the presented records.
  • Ignoring Electronic Health Records (EHRs): Modern healthcare often involves electronic records that might contain data not present in traditional paper files, such as time stamps or audit trails. Overlooking these can mean missing out on crucial information.

Contact an Experienced Medical Malpractice Lawyer at Matzus Law, LLC for a Free Consultation About Your Case Today

Medical records are invaluable in a malpractice claim. They provide the objective evidence needed to substantiate claims and can be the determining factor in the outcome of a lawsuit. With the right approach to gathering and presenting this evidence, individuals can bolster their cases and seek the justice they deserve.

If you or a loved one believe you have a medical malpractice claim, don’t navigate these waters alone. Partner with experienced professionals. At Matzus Law, LLC, we’re dedicated to ensuring that your case is backed by the strongest evidence possible. Reach out today, and let’s work together towards the justice you deserve.


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