Medical records tend to be voluminous and intimidating. It seems impossible to get them on time and complete on the first try, and when they do arrive, you can't read the hand-written notes or make sense of the typed ones. I may not be able solve those problems for you, but I do want to share several best practices for getting the records you need and managing them throughout the case.
- Complete Records. It is not unusual for medical records to be incomplete. Human error may result in double-sided originals only being copied on the front. Or, for electronic records, an entire day or treatment may be missing if the physician forgot to sign off on it. In addition to the records, did you get the medical bills and films that you asked for? The right time period? We had a case with a patient whose name was spelled three different ways across different facilities so we had to send multiple requests.
- Cross-reference. This is related to getting complete records, but important enough to be a stand-alone tip. Be sure to cross-reference the records you receive with the bills. Do you have all the treatment that was billed? All of the treatment or providers listed in discovery or at deposition? If films were reviewed, do you have those films? Do you have treatment and orders to correspond with prescriptions they filled?
- Sending out Records. If you send records out to other parties or experts, make sure you keep a copy of exactly what was sent. You may receive updated records or missing records and months later, you may not recall exactly which records were sent to your expert. It is okay to scan records to send, but be mindful of HIPAA so don't email them in an unsecured manner. Also, make the necessary redactions before filing the records in court or presenting at trial.
- Bates numbering. Some attorneys bates number all of the records as they come in so that anything produced to other parties or referenced in a deposition can be identified later. Some attorneys bates-stamp them upon arrival, while others wait until closer to trial when all updated records are in.
- Chronology and Summary. One of my favorite tools is a medical chronology and summary of the plaintiff's treatment. It identifies the key events and treaters and clearly lists them in a chart. The chart should show the dates of treatment, provider, brief description, and notes about its importance, any definitions, and follow-up needed. This is an easy reference for preparing for depositions and timelines for trial.
Melanie S. Taylor is a partner with Bendin, Sumrall & Ladner, LLC, in Atlanta, Georgia. Her medical malpractice and business litigation practice represents corporations, business owners, hospitals, and individual medical providers in matters ranging from risk management to litigation. Ms. Taylor is counsel for businesses ranging in size from start-ups to Fortune 100 companies in the retail, financial, and construction industries. She advises her clients on how to mitigate risks, best practices after becoming involved in litigation, and alternative dispute resolution. Ms. Taylor's representation involves preparing her clients and experts for all stages of litigation and defending against allegations of professional or ordinary negligence, wrongful death, and agency and employment relationships and other liability claims. Prior to joining Bendin, Sumrall & Ladner, LLC, she was a litigator with large national firms, where she worked on cases involving class actions, construction, mold, product liability, contracts, insurance defense, pharmaceuticals and general litigation. Ms. Taylor graduated, with honors, from Duke University with joint degrees in political science and Spanish then matriculated to Georgetown University Law Center in Washington, D.C.
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