Medical record

If you have received medical treatment and believe that your doctor or other care provider made a mistake that harmed you, you might be thinking about filing a medical malpractice claim. As medical malpractice attorneys who represent patients, one question we often get is, “Do I have to have a copy of my medical records before I can talk to a medical malpractice lawyer?”

The short answer is: no, you do not have to have your medical records in hand before you talk to a lawyer about your potential claim. If you happen to have any of your records, of course, they might be helpful to the attorney in evaluating whether you have a case. But given the fact that you have only a limited amount of time in which to file a claim, it makes sense to speak to an attorney as soon as possible, records or no records.

That said, it’s also a good idea to request a complete copy of your medical record before actually filing a claim for medical malpractice. In this blog post, we’ll talk about why.

What is in Medical Records?

Depending on the type of medical provider, your medical records may contain many different documents and types of information, including:

  • Medical history: When you first started working with a doctor or hospital, your provider asked you a series of questions (often on a form or questionnaire) regarding your personal medical history and possibly that of your family. That information is used to guide doctors in making diagnoses and treatment decisions; for instance, if you have a strong family history of colon cancer, your doctor might call for more aggressive screening for you, especially if you report symptoms consistent with the disease.
  • Presenting complaints: Your medical record should indicate the reasons you contacted your provider for care, including any symptoms you reported.
  • Reports of physical examinations: Your medical record also includes documentation of any physical examinations your provider performed on you, including any signs of disease.
  • Laboratory, imaging, and other test results: your doctor may have ordered a number of tests (such as blood tests, X-rays, and other imaging) for you based on your complaints, medical history, and their own observations. Those tests are important in determining what conditions you may have and how they should be treated. Failing to order tests that are called for, failing to properly interpret results, or failing to notify you of results may all constitute medical malpractice.
  • Surgical records: If you have had surgery, the details of what was done and any unusual events that arose during the surgery should be recorded.
  • Prescription records: Your medical records should contain a list of your current prescriptions, including any medicines you were prescribed during a hospital stay or upon your discharge from the hospital.
  • Vital signs such as heart rate, respiration, and blood pressure
  • Clinical notes: Doctors and nurses include their observations and other notes in your medical chart, as well as notes regarding treatments administered and your response to treatment.
  • Consultation reports: If your provider consulted with a specialist regarding your diagnosis or treatment, a report of the communications should be in your medical record.
  • Discharge instructions: whether you were in the hospital or at an office visit, it’s likely your provider gave you instructions for follow-up care.

These are only some of the many components of your medical records, and some of the many places that clues about potential medical malpractice could be hiding.

Requesting Medical Records Ahead of a Medical Malpractice Case

Asking for your medical records before filing a malpractice claim is important for a number of reasons. As mentioned above, the more information your medical malpractice attorney has, and the sooner he or she has it, the better.

But there are other reasons as well. If you wait until after your case is filed, the provider may “slow walk” your request, taking the maximum allowable time to provide you with the requested documents. Although they are not supposed to do so, there also exists the possibility that an unscrupulous provider could alter records after the fact to try to conceal evidence of medical malpractice. Asking for your records before filing a claim could reduce the chances of your provider doing something unethical.

You have a right to your own medical record. To expedite the process, make your request in writing (via e-mail is acceptable) and be specific, including your date of birth and/or medical record number, and the dates of your treatment. If there is any specific information you want, be sure to identify it. You can ask for just a portion of your record, or the entire record. You also generally have a right to receive your medical record in the format you request (such as printed or digital), so if you have a preference, specify that as well.

Your provider should respond to you within 30 days, but while you are waiting, remember that you may already have access to a portion of your medical record. You might have printed visit summaries or discharge instructions from prior visits, and you may be able to access part of your record online through a patient portal such as “MyChart.”

To learn more about the importance of your medical records and how to request documents from your medical provider, contact The Fraser Law Firm P.C. to schedule a consultation.