Our Services: Medical records
Top Ten Hints for Medical Records Management: Attorneys Will
Save Time and Money by Avoiding These Pitfalls.
 1.
Be very specific about whether you need a certified medical record
or an abstract. A medical malpractice case involving a specific
admission would be difficult to evaluate without a full certified
copy of the medical records.
2. Be aware that the production
of the nursing home chart
is regulated by the Federal Government. Under 42 CFR 483.10, the
nursing home is required to produce a medical record within 2
working days of a request. “The resident or his or her legal
representative has the right (1) upon an oral or written request,
to access all records pertaining to himself or herself, including
the clinical records, within 24 hours (excluding weekends and
holidays); and (2) after receipt of his or her records for inspection,
to purchase at a cost not to exceed the community standard, photocopies
of the records or any portion of them upon request and two working
days advance notice to the facility.”
3. Use a logical system for staying
on top of medical records requests so your office will know when
to send a second request.
4. Don’t accept a poor quality
copy of a medical record. A poor copy may be light, misfed into
the copier so that only part of the page is visible, or missing
pages. A copy that is double sided, with the pages jumbled and
placed front to back in random order, will be almost impossible
to follow.
5. Don’t put yellow or pink
highlighting on the medical records you forward to the expert.
The expert may have to explain that highlighting in a deposition
one day. The other side may assert that the highlighting assumes
the expert cannot find the relevant material without hints from
the attorney.
6. Do have someone with medical
knowledge organize records before they are sent to an expert
or consultant. Organizing means using hospital or nursing home
tabs to divide medical records into sections. You will save money
on expert witness bills by sending organized records.
7. Don’t jumble medical records.
Hospital and nursing home records should be organized chronologically
within each section of the records. For example, the physician
orders should start with the initial set written when the patient
was admitted to the hospital, and end with the discharge order.
8. Don’t send your expert your only copy of the medical
records. You may need to refer to them while the expert has them.
9. Don’t send medical records
by a method by which they cannot be tracked if lost.
10. Don’t send physician’s
office records without identifying the name of the physician on
a cover sheet or without the records request letter. It may be
difficult for the expert or consultant to determine the author
of the records without this identification.
Contact
us for more information about how we can help attorneys with
records.
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