"Everything you've been told about building
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Your Checklist for Medical Records

Almost as an afterthought, medical records are received by your office and they get filed. You give little thought to the medical records until the day before the defendants’ deposition when you realize—for the first time—that you received an incomplete set of records. By then it’s too late—you don’t have enough time to get the medical records that you need.

You can avoid this problem by creating a system for reviewing medical records. Once the medical records are received, your paralegal should complete a “Medical Records Checklist” that lists the medical records that were requested and compare that to the medical records that were received. WARNING! Hospitals and doctors rarely comply with requests for medical records.

When medical records are received, have your paralegal complete the “Medical Records Checklist” and bring it to you for review. This is your stop-gap measure to ensure that you receive a complete and accurate set of medical records. Once you confirm that you received the complete and accurate set of the medical records, sign and electronically file the “Medical Records Checklist”.

This is our “Medical Records Checklist”:

Our Medical Records Checklist

Name of Patient and Medical Facility

Name of Patient:           _____________________

Medical Facility:            _____________________

Dates of Treatment:      _____________________

Date of Request:              _____________________

Records Received on:     _____________________

Records Requested Records Received
Discharge Summary: __ __
Operative Report: __ __
Laboratory Result: __ __
Imaging Reports: __ __
Nurse Progress Notes: __ __
Physician Progress Notes: __ __
Physician Orders: __ __
Consultation Reports: __ __
Medication Record (“MAR”): __ __
History and Physical: __ __
Discharge Instructions: __ __
Consent for Surgery: __ __
Registration Form: __ __
Billing Records: __ __

Request Satisfied by Medical Facility: YES__  NO__

____________________________       Dated: February 27, 2017

Travis VanDeWater, Paralegal


____________________________       Dated: February 27, 2017

Corina Skidmore, Paralegal


____________________________       Dated: February 27, 2017

John H. Fisher


photo credit: Mufidah Kassalias Checklist Chalkboard via photopin (license)

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