How Medical Records Are Kept & Where They Are Found

When you begin any personal injury case, one of the most crucial elements to strengthening and building your case is your medical records. "Medical records" is a broad term for any and all written documentation that holds the details of your injuries, recovery, and hospitalization. This can include, but is not limited to: X-rays, doctor's opinions, physical examinations, medical history, surgical history, and any other documentation that pertains to your experience with doctors or a care center. These documents are vital to the creation and pursuit of your case in court. Unfortunately, the healthcare industry also knows how vital these documents are to medical malpractice cases as well. Though you are entitled to your own medical records, you may be met with resistance from the hospital. The process of obtaining medical records can be stressful and arduous once a care center goes on the defensive.

Who Holds My Medical Records?

Typically, all medical records are held at the place of care where they were generated. However, because prior care centers are not always easily accessible to former patients, this may prove to be difficult. At times, large care centers, such as a local hospital, will make use of a third party record keeping agency to store your records. This means that your records may be more difficult to obtain. It is important to remember that at the time of your treatment, and during your discharge you can request copies of any and all pertinent records for your own filing. This is not only a great habit, but it can also streamline your medical malpractice claim if you already have the relevant records readily available to bring to your attorney.

Personal Health Records

A simple way to not have to worry about pesky hospitals slowing down you case is to keep your own personal health record, or a PHR. Personal health records are controlled by you and available right at your fingertips. They can be offered through your healthcare plan, your employer, or an independent service.

  • Standalone PHR: With a standalone PHR, patients fill in their own information using their prior records and their own memories. Data can be stored on the patients own computer or through an Internet database. PHRs can be directly managed by the patients themselves or by an independent record keeper. A standalone PHR is not typically protected by HIPAA.
  • Tethered/Connected PHR: A Tethered/Connected PHR is a PHR that is linked to a healthcare organization or larger system. These are typically held through hospitals or other means and are protected by HIPAA.

How Can I Get My Medical Records?

When you have to retrieve your medical records, you should be entitled to any records that pertain to your case. Be forewarned, however, that medical records are very sensitive information, and cannot be given out to just anyone. Under HIPAA only properly privileged individuals can obtain medical records. Many healthcare administrative services will deny access to anyone but you, unless they have the proper permissions. At times, your attorney may be able to obtain the information for you, so long as it can be confirmed that they represent you. Some healthcare administrators may have their own permission forms that you must fill out in order for your attorney to gain access. Once permissions have been completed, there are a few ways that you or your attorney can obtain records.

In Person Or By Request

One simple way that you may obtain your medical records is by doing so yourself. Since access to your own records is guaranteed through HIPAA, you should be able to obtain your own records in person. The only exception to this would be in the case of medical information that has a risk of causing the patient to inflict physical harm upon themselves. The only typical situation where this would apply would be the release of mental health records where self-harm or suicide may occur.

At times, healthcare administrators may force you or your attorney to jump through hoops to get your records. Depending on the administrator, hospital, or state guidelines, you and your attorney may have specific forms or letters to fill out in order to request those records. Once filed, these request forms or letters will be fulfilled and the documents can be sent to you or your attorney or picked up by you or your attorney. The entity that you retrieve your records from may charge you for the copies generated, depending on your state's guidelines.

If the healthcare administrator holding your records is meeting you with stonewalling tactics, or taking an extremely long amount of time to get you your records, there are certain steps for solutions that can be taken.

Subpoena

When your case has been filed, and the healthcare administrator holding your records has still not provided you with your records, you and your attorney have one course of action that can guarantee a release. Medical records can be subpoenaed. Your attorney can help you with retrieving records through a subpoena. A subpoena is a court order to release the records and add them to the evidence of the case, depending on evidentiary rulings. Subpoenas must be fulfilled by the healthcare administrator by law, so this can be used if you are facing stonewalling tactics.

If you or a loved one has been the victim of medical malpractice or hospital negligence, the process can be taxing and frustrating. You will want the help of a skilled and experienced attorney to get you through it. Contact the legal professionals at Gilman & Bedigian today.

Let Us Help

If someone you are close to has been seriously injured or worse, you are naturally devastated not only by what has happened, but by the effect that the injury or loss has had on you and your family. At a time when you're vulnerable, traumatized and emotionally exhausted, you need a team that will support you through the often complex process that lies ahead.

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