Electronic medical records are here to stay even though only a small percentage of hospitals in the United States have implemented the same and qualified for federal incentive payments. Medical records are an important element in medical litigation and lawyers handling insurance defense and personal injury cases will have to acquire all relevant medical documents, whether electronic or paper, for purposes of review. Here are some important things to consider when requesting medical documents pertinent to a case.
- Acquire a complete copy of the records.
- Request also for the private health information disclosure log, which shows what, when, where and by whom a patient’s records have been distributed. This is important because it will enable you to find out whether other copies of the medical records are out there that you can compare with.
- Ask for the audit trail if you find that physicians’ orders within the medical chart are problematic. You may find that details in the chart such as the person who made the order, the time of the order and the nurse who noted it, are missing. The audit trail will include all additions, deletions and modifications made to the orders. It will give a clear picture as to who has looked at the medical records, when they looked at them, how long and also whether a hard copy of the medical chart had ever left the medical records department.
- Ensure that all providers who administered medication have signed/recorded their name in the medical chart. The concerned nurse has to substantiate that the medicine was administered.
- Electronic records of nurses’ notes tend to be slightly confusing because it may contain specific terminology that the facility uses in connection with their EMR. To understand these entries you may need to obtain the data dictionary from that healthcare facility. Here too, an audit trail can reveal the identity of the nurses who provided care, when they provided it and when they recorded that information.
- Some facilities may have a hybrid system comprising both paper and electronic records. Make sure that you obtain all these, whether paper or electronic because the combined chart may indeed be the entire chart.
