Thursday, March 15, 2007

Keeping Family Medical Records is Essential

It is absolutely essential to keep a personal copy of ALL your medical records - and also those of family members.

I ran across this list of 11 "Reasons" from a Nurse Consultant for an attorney's office.  Hopefully you will never have to sue of physician.  But understanding your medical information and "letting your doctor know that you know" will make it LESS likely that you will have "communication problems" and more likely that you will receive the very best possible treatment.  Doctors are human like the rest of us; they make mistakes.  

Do everything you can to prevent yourself or a family member from becoming a victim:

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Tips for Requesting and Reviewing Medical Records
By Janabeth Evans (Taylor), R.N., R.N.C.

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.

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