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.
Components of the Medical Record
HOSPITAL RECORDS
Hospital records include, but are not limited to:
Admission Information/Summary – documents date/time of admission, admitting diagnosis. Admitting physician and other basic admission information
Discharge Summary – documents condition at time of discharge, any post discharge instructions for lab tests, physician appointments and medications prescribed, as well as instructions for physical activity and other treatment modalities.
Admission History and Physical – documents condition at time of admission, usually performed by admitting physician, but sometimes deferred to a medical resident or physician assistant. There may also be a separate document, “Physician’s Admission History and Physical” in some health care facilities.
Physician’s Progress Notes – daily chronology of patient’s progress, often gives rationale behind change in treatment or medication and documents physician visits.
Emergency Room Records – documents condition upon arrival, chief medical complaint and may also include emergency room physician evaluation of any tests performed such as ultrasound, radiology and laboratory tests. Also recommendations for referral, admission and/or discharge are obtained here.
Consultation Reports (Physician and other professional.) documents evaluation and recommended treatment by physicians, and other health care providers asked to consult in reference to patient care.
Physician’s Orders – documents date and time of treatments and medications ordered by treating physicians. These are to be signed by the physician ordering, even if a telephone order or phone/verbal order given to a nurse.
Operating Room Records and Report (Physician, Nursing and Anesthesia Record) – documents procedure performed, surgeons, nurses and anesthesia personnel present during surgery. Also documents patient condition before, during and after surgery. Some hospitals document post operative care in the “PAR” (post anesthesia recovery) record.
Laboratory Reports – documents results of tests performed in the laboratory. Includes not only blood and urine tests, but also cultures of tissue and microscopic exam of tissue.
Graph Sheets – documents basic vital signs and other basic functions such as urinary and intestinal elimination. Some graphic sheets also document dietary and fluid intake.
I and O record – documents fluid and solid intake and output on a daily basis. Usually tallied on a daily basis, but may be recorded with each shift (two to three times a day)
Treatment Sheets – documents all manner of treatments such as wound care, hot and cold therapy not given in physical therapy, etc.
Medication Sheets – documents medications given. PRN medication is given on an “as needed” basis and may be listed separately from regularly scheduled medications.
X-ray/Radiologist Reports – documents radiologist’s impression of radiology tests. Will also contain name of ordering physician.
Physical Therapy Records – documents treatments/therapy given in the Physical therapy department as well as the patients response to therapy.
Speech Therapy Records – documents therapy given by speech pathologist.
Occupational Therapy Records – documents therapy given by occupational therapist. May be included as part of physical therapy records in some institutions.
Nurse’s Notes/Nursing Progress Notes – Chronological documentation of patient’s condition, physician visits, change in condition and treatments given as well as patient responses. Usually written in longhand, but more and more frequently are seen as a computerized record.
Nursing Care Plans – Each patient has a general plan of care, and the foundation is determined by the policy of the health care facility. However, generally the nursing care plan covers all treatments, medications and therapies ordered for the patient. Goals are also stated for patient care.
Interdisciplinary/Multidisciplinary Progress Notes (Not utilized in all facilities.) – documents progress of each therapeutic department in chronological order, rather than a separate progress note maintained by each department. May include notes made by more than one department, such as speech, physical and occupational therapies.
Other records found but not consistently maintained by all facilities may include:
- 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) – these records may be maintained by either an independent EMS service or a municipal fire department, or hospital EMS 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, the records of 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 records, and a separate request for each entity will be required in order to obtain all records.
Building Your Medical Library
Whether your practice involves a client injury in the workplace, injury due to medical negligence, product defect, or toxic chemicals you will have a need to obtain and review medical records.
At times the terms used in the medical records can be confusing and the rationale for diagnosis and treatment is not clear. In other instances you wish to review a standard of care as it relates to your client’s diagnosis and treatment.
Below is a general listing of resources, both in text print as well as online which might be of benefit to your office.
We are all sensitive to the issue of overhead for the law office. Therefore, you may want to consider obtaining some of these books as library materials for a shared legal medical library established through your local bar association or in co-operation with other law firms in your immediate area.
Medical Abbreviations: 24,000 Conveniences at the Expense of Communications and Safety, by Neil M. Davis
Temple Univ., Philadelphia, PA. Annual pocket quick-reference guide to 24,000 meanings of medical abbreviations and 3,400 cross-referenced generic and brand drug names. Thumb-tabbed pages. Includes single-user access code to the Internet version of the book which is updated with 80-120 new entries per month. Softcover.
Laboratory and Diagnostic Tests with Nursing Implications (6th Edition)
Each test is discussed in seven subsections in the following sequence: (1) reference values/normal findings, (2) description, (3) purpose, (4) clinical problems, (5) procedure, (6) factors affecting laboratory or diagnostic results, and (7) nursing implications with rationale. Following the name and initials for each test, there may be names of other closely associated tests. Reference values/normal findings are given for children and adults, including the elderly. The description focuses on background data and pertinent information related to the test. The general purpose for each test is listed. Clinical problems include disease entities, drugs, and foods that cause or are associated with abnormal test results. The procedure is explained with a rationale for the test and with appropriate steps that the nurse and other health professionals can follow. Factors affecting laboratory or diagnostic results alert the nurse to factors that could cause an abnormal test result. The last subsection and most valuable information for each test concerns the nursing implications with rationale. For most diagnostic tests, nursing implications are given as “pretest” and “posttest.”
Alexander’s Care of the Patient in Surgery
ALEXANDER’S CARE OF THE PATIENT IN SURGERY, considered the standard in perioperative care for over 50 years, is a comprehensive reference for students and practitioners alike. Unit I covers basic principles and patient care requisites. Unit II details step-by-step procedures for over 400 general and specialty surgical interventions. The unique needs of ambulatory, pediatric, geriatric, and trauma surgery patients are discussed in Unit III. New features include highlighted patient education and discharge planning, sample critical pathways, expanded coverage of endoscopic/minimally invasive procedures, and internet resources. A new chapter, Surgical Modalities, addresses today’s technologically advanced perioperative environment.
Merck Manual Diagnosis & Therapy (Includes Facsimile of 1st ed. of the Merck Manual)
The most widely used medical text in the world and the hypochondriac’s bible, the Merck has the lowdown on the vast expanse of human diseases, disorders and injuries, as well as their symptoms and recommended therapy. It’s intended for physicians and medical students, but though the type is tiny and the language technical, the Merck’s a valuable volume for anyone with more than a passing interest in bodily ills.
Rosen’s Emergency Medicine: Concepts and Clinical Practice (3-Volume Set)
ROSEN’S EMERGENCY MEDICINE continues to be the premier source that defines the field of emergency medicine. It describes the science of emergency medicine and its application, focusing on the diagnosis and management of problems encountered in the emergency department. This stellar new team of editors has introduced many new features including a “Cardinal Presentations” section, chapter consistency, and more diagnostic imaging throughout. All existing chapters have been extensively revised, and reference lists have been edited to include more significant, up-to-date references.
Joint Commission on Accreditation of Healthcare Organizations. (CAMH) Comprehensive Accreditation Manual for Hospitals: The Official Handbook: Accreditation Policies, Standards, Scoring, Aggregations Rules, Decision Rules.
Oakbrook Terrace, IL, Joint Commission on Accreditation of Healthcare Organizations, 2001. CAMH, $350.00; CAMH and 1-year update, $565.00; CAMH annual subscription update, $245.00.
Cecil Textbook of Medicine (Single Volume)
Cecil Textbook of Medicine, 21 Edition CD-ROM provides rapid-access to the complete text, illustrations, tables and references. Review questions with answers are linked to the relevent sections of the textbook and complete drug monographs from Mosby’s GenRx are included. Plus, this CD-ROM gives you FREE access to Cecil Online! –This text refers to the CD-ROM edition.
Current Pediatric Diagnosis & Treatment
Provides clinical information on ambulatory and inpatient medical care of children from birth through adolescence, focusing on clinical aspects of pediatric care and their underlying principles. Emphasis is on ambulatory care, acute critical care, and a practical approach to pediatric disorders. This edition contains new chapters on developmental disorders and behavioral problems, substance abuse, allergic disorders, and fluid, electrolyte, and acid-base disorders and therapy, plus expanded illustrations.
Clinical Nursing Skills & Techniques
The 5th edition of Clinical Nursing Skills and Techniques offers new up-to-date content and improved features, in addition to complete coverage of more than 200 nursing skills, a nursing process framework for a logical and consistent presentation, and a convenient 2-column format with rationales for each skill step.
Critical Decisions in Emergency Medicine, reliable, relevant clinical updates/risk management. two lessons each month. Subscription for non member $244 a year.
Index of past issues found at:
Order by calling ACEP or going to and order online
ACEP – Foresight CEU Risk Management
Example:
Print monthly from online resource.
AMA – Medicolegal Forms with Analysis – Documenting Issues in the Patient-Physician Relationship.
Covers issues such as consent, informed refusal, ama, and others. Contains current forms and references to legal citations related to each issue discussed.
Other suggested Book Lists/Links
Brandon/Hill selected list of print books and journals for the small medical library
“Selected List of Books and Journals for the Small Medical Library” was published almost forty years ago, this series of selection guides has been heavily used and highly valued by librarians, nurses, health care practitioners and publishers. The Small Medical Library list was followed in 1979 by the “Selected List of Nursing Books and Journals” and by the “Selected List of Books and Journals in Allied Health Sciences” in 1984. In 2001, the publications were made available on the internet, promoting unrestricted access.
It was always the instruction of Alfred Brandon and Dorothy Hill, the original authors, that the selected lists would not be published under their names without their direct involvement which is why they retained copyright of the lists. With the recent retirement of Dorothy Hill, this longstanding project has drawn to a close.
Brandon Hill Journal Links
This list of Journals available in full text online was updated on a regular basis by the National Library of Medicine through May 12, 2003, This page is valuable in terms of information to online resources, but this page, “MLA Brandon/Hill Journal Links”, is no longer updated.
General Reference Internet Links
Medscape
Medscape is a multi-specialty Web service for clinician and consumers that combines information from journals, medical news providers, medical education programs, and materials created for Medscape. Here you will find a combination of peer-reviewed publications, a free version of drug information via the “First Data Bank File” and free Medline.
MD Consult
Founded by leading medical publishers that include Mosby and W.B. Saunders, MD Consult integrates peer-reviewed resources from over 50 publishers, medical societies, and government agencies. From this site you can obtain full text from respected medical reference books from a variety of specialties, medical journals, and MEDLINE. In addition you can obtain comprehensive USP drug information (beyond the scope of a PDR), as well as more than 600 clinical practice guidelines. This is not a free service, but for a small fee you can have access by the day, month or year. Also there is a free seven day trial membership.
Guidelines Clearing House
This site is a public resource for evidence-based clinical practice guidelines. NGC is sponsored by the Agency for Healthcare Research and Quality (formerly the Agency for Health Care Policy and Research) in partnership with the American Medical Association and the American Association of Health Plans. A medical term search will retrieve objective, detailed information on clinical practice guidelines. Results in a search will obtain: structured abstracts (summaries) about the guideline and its development, a utility for comparing attributes of two or more guidelines in a side-by-side comparison, syntheses of guidelines covering similar topics, highlighting areas of similarity and difference, links to full-text guidelines, where available, and/or ordering information for print copies and, annotated bibliographies on guideline development methodology, implementation, and use.
CPT Codes
This website gives users of CPT the opportunity to perform CPT code searches and obtain information about Medicare’s relative value payment amount associated with the codes. Searches can be performed using 5 digit CPT code numbers or key word(s) in the code description. Also you can order the CPT coding handbooks in paperback format. The codes are updated annually.
