Medical Records
A List of Suggestions and Ideas for Obtaining Medical Records,
Including Often-Overlooked Documents

This is a list of medical documents and their sources within a healthcare facility.
1.This is provided to assist an attorney in obtaining a complete set of medical redcords
2.WE DO ORGANIZE RECORDS FOR ATTORNEYS - SEE THE "FEE AND SERVICE" LINK ON THE LEFT.
3. NOTE: THIS IS NOT FOR THE GENERAL PUBLIC. PLEASE DO NOT ASK US TO LOCATE YOUR OLD MEDICAL RECORDS. WE DO NOT PROVIDE THIS SERVICE.

HINTS:
- MANY MEDICAL RECORDS, ESPECIALLY NURSIING DOCUMENTS, ARE MULTIPLE PAGES WITH DATES AND SIGNATURES ONLY ON ONE PAGE. REQUEST THAT MULTIPLE PAGES BE STAPLED IN ORDER. THIS IS CRUCIAL FOR ESTABLISHING TIMES/DATES.

- OFTEN TREATMENT AND MEDICATION RECORDS ARE DOUBLE-SIDED WITH INITIALS, SIGNATURES AND COMMENTS ON THE REVERSE SIDE. BE SURE TO REQUEST DOUBLE-SIDED COPIES OR HAVE SINGLE-SIDED COPIES STAPLED TOGETHER. This can be 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.

MEDICAL RECORDS

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.

Information is often obtained from seemingly obscure records, hence the need for ALL of the medical 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 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.

HOSPITAL RECORDS

Hospital records include, but are not limited to:
- Admission Information/Summary
- Discharge Summary
- Admission History and Physical
- Physician's Progress Notes
- Emergency Room Records
- Consultation Reports (Physician and other professional.)
-Physician's Orders
- Operating Room Records and Report (Physician, Nursing and Anesthesia Record)
- Laboratory Reports
- Graph Sheets
- Treatment Sheets
- Medication Sheets
- X-ray/Radiologist Reports
- Physical Therapy Records
- Speech Therapy Records
- Occupational Therapy Records
- Nurse’s Notes/Nursing Progress Notes
- Nursing Care Plans
- Physician history and physical (including admission history and physical)
- Physician Progress Notes
- Physician Discharge Summary
- Interdisciplinary/Multidisciplinary Progress Notes (Not utilized in all facilities.)

ALSO LOOK FOR

In non-hospital settings, especiallly nursing homes and assisted liviing facilities, some terms for the documents used will be the same and some will not be. Look for these items in addition to the ones listed under hospital records:

· KARDEX files (Yes, some facilities use these.)
· MAR or MARS sheets (Medication Administration Record Sheets)
· Nurse Aids or Nursing Assistants Notes (N A) or Certified Nursing Assistant (C N A) Records/Treatment Logs
· Treatment Records, Nursing Treatment Records (Sometimes in with the medication records; sometimes listed separately.)
· Physical Therapy
· Speech Therapy
· Occupational Therapy
· Rehabilitation Therapy, Restorative Services
· Recreational Therapy, Activity Therapy or Service
· Any other form of therapy records
· Visiting Nursing or Home Care Nursing Records
· Records from Independent Medical Laboratories
· Records from Independent Radiology and Nuclear Medicine Services
· Ambulance Records (EMS --- Emergency Medical Service)
· Emergency Room Records (These are often not part of the hospital records, where the emergency room is operated by an independent contractor.)

In some situations, emergency response personnel such as the local police and rescue portions of the fire department will also apply and will be separate from other EMS personnel in the storing of their records.

If a facility is state licensed, obtain a copy of the state’s investigation and licensing inspections for the year(s) being investigated. [Generally, this is a matter of public record obtained from the designated state regulatory agency.]

We realize that not all of these records will be necessary for a brief Initial Report for the determination of deviations from standard medical practices [medical negligence]. We will be happy to work with you to help you tailor the list of medical records you will need to obtain, especially if you only need to establish the existence of deviations from standard medical practices [ medical negligence]. However, with more medical records available to us, we will be able to more easily and more accurately establish or eliminate medical negligence. For an Expert Report, it is ABSOLUTELY CRITICAL to have ALL available medical records.

Home   

Back to Legal Professional Page

L D H P Medical Review Services Corp. 4801 Montano Road N. W. Suite A-6 - PMB 145 Albuquerque, New Mexico 87120 Telephone (505) 890-8105 Toll free: (877) LDHP-MED or (877) 534-7633