No, you can’t have your full records. They belong to us.

Obtaining medical records is key to understanding what happened to a plaintiff. They provide (or at least should provide) a detailed summary of important information including a person’s symptoms, diagnostic testing, consultations, treatments, and medications…to name a few.

Perhaps even more important, they are also the way that health care providers can communicate with each other to assure that a patient receives the best care, that there is no unnecessary duplication of tests, and that crucial information is shared with all the providers involved in the patient’s care.

Basically, they should be a safety net to assure that someone does not fall through the cracks.

So what’s the problem? Obtaining medical records has become increasingly challenging…to say the least. And as healthcare becomes more complex, the task of assuring that patients and their providers have received the ENTIRE medical record becomes monumental.

The Challenge in Obtaining Medical Records

I had a lesson in this today as I spent hours trying to help a friend who needed to obtain his records from previous treating urologists for his current urologist. He had treated with three other urologists and thought they were all in the same practice.

I had the names of all the doctors and the office phone number. I thought all I would need to do was to contact the office to find out where we needed to send a request to release medical records.

WRONG!

The Cold Stone Wall in Obtaining Medical Records

When I called the doctor’s office to obtain the medical records, the receptionist told me when we faxed the request, she would only be able to supply the records for the one visit he had with this particular doctor.

I would have to contact the other doctors for records of his visits with them. Was she kidding? I said, “Wait a minute. My friend thought all these physicians were affiliated.” He called the same phone number for appointments.

If he had symptoms, he was given an appointment with whoever was covering that day. I was simply told that she could still only provide the records for the single visit with this doctor; I would have to call the other doctors separately!

I called another doctor’s office to obtain the medical records and was told a totally different story. The young woman on the phone said that she could see the records for all the visits my friend had with all three doctors; I could simply fax a signed release to her and she would fax my friend’s records to his current urologist. Wonderful! I knew the first explanation couldn’t be correct…it made no sense. But…I had a nagging suspicion that this had been too easy.

Sure enough, the receptionist had second thoughts and wanted to check with the manager. You guessed it…now she too would only be able to provide the records for this one physician…not all the visits/records…even though she had access to the entire record.

I tried pleading, arguing…and of course got nowhere. I even said to her, “So at this point, the only one who can’t have access to his entire record at the same time is my friend?” She said, “Basically…yes.” She explained that these doctors were affiliated with a “corporate entity” but practiced as independent providers. I asked if patients were told that. Of course, I did not get an answer.

Disaster Lurking in the Medical Records?

This seemed like a system just waiting for disastrous consequences for patients. If the doctors don’t really communicate or work together, how do they make sure that patients don’t fall through the cracks? Apparently, they don’t.

Unfortunately for my friend, he fell through a large crack. There was a delay in the diagnosis. His prostate cancer went untreated for almost a year.

All kinds of tests had been done but no one took the responsibility for actually reviewing the results. They never told him he had cancer. I guess the “corporate entity” does not understand the vital importance of medical records.

Shame on them…

Unfortunately what started as a challenging attempt to obtain medical records revealed more than we expected. This was a huge “eye-opener” for me as a nurse. What vital information is hiding in your records?

Jane D. Heron, RN, BSN, MBA, LNCC is a legal nurse consultant at Med League.

Med League provides medical expert witnesses to trial lawyers. Please call us at (908)788-8227 or contact us today to discuss your next case.