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Top 10 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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