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)
