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Medical Records: Understanding Your Case

The Becker Law Firm, LPA

The first step in truly understanding what happened during labor and delivery is a close inspection of the medical records. As a patient, you have the absolute right to your medical records. The issue of how soon you can get them, and what the cost will be depends on the state law and the facility’s rules.

Types of Medical Records Used to Evaluate Birth Injury Claims

In general, most lawyers will want to look at the following records:

  • Prenatal records: Usually the obstetrician and/or gynecologist will have prenatal office records detailing patient condition and complaints prior to delivery.
  • Hospital admission records and discharge summary: These hospital records will give a good summary of the entire scope of care of the mother and baby. Importantly, the mother’s discharge summary may be separate from the baby’s discharge summary, because at the time of discharge they are two separate patients.
  • Physician orders and progress notes: These records will detail the obstetrician and other doctor’s instructions and interpretations.
  • Nurse’s notes: The nurses are charged with carrying out the doctors’ orders and monitoring the mother and baby during labor and delivery. These notes will show their interpretations throughout the process.
  • Operative notes: If a Cesarean section or other medical procedure was performed, these records will detail the purpose, scope and process of the procedure.
  • Laboratory/pathology: Any lab work (on blood, amniotic fluid, urine, or even the placenta) will be shown in these records
  • Radiology/imaging: Ultrasound and MRI may be part of a separate department in the hospital. Lawyers may need to order the reports and/or copies of the full scans.
  • Electronic Fetal Monitoring: The continuous monitoring of the mother’s contractions and the baby’s heartrate should be recorded and part of the complete medical records. These records should reveal whether the baby was in any danger due to oxygen deprivation.
  • Prior records: Depending on the type of birth injury, the lawyers and their experts may need to look at records from prior primary care providers, hospital deliveries or obstetrician/gynecologist records. Those could yield important information about the mother’s medical history which may be relevant to a later labor and delivery.

The records oftentimes number in the hundreds or thousands of pages, depending on how long the hospital admission was, and what level of complications were encountered. They will often come from the hospital and doctors in seemingly random order—the lawyer and staff is responsible for organizing them.

Electronic Medical Records

Many hospitals and doctors’ offices have migrated from paper records to electronic medical records. These records can be incredibly useful for those who know how to read them. In particular, electronic medical records have something called metadata. For each notation, it should be possible to determine exactly when the entry or record was created and updated. This information will help lawyers to determine whether records were changed after the fact.

However, there are downsides to electronic medical records. Some doctors and health care providers may be less tech-savvy, and may not type as much information as they would if they had a pen and paper. The lack of full information could make proving a claim for medical malpractice more difficult.

Contact Us

You do not need to have your medical records before you hire a lawyer. Lawyers have experienced office staff who can order the necessary records and bills. However, if you do have any records, be sure to provide those to your lawyer at your first meeting, to give them a jump on your medical malpractice claim. For more information about medical records and proving a birth injury claim, contact our medical malpractice attorneys at (440) 252-4399 or online for a free consultation.

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