Accessing Records In Electronic Form To Use In Medical Malpractice Case

Individuals in a medical malpractice case have a right to electronic records from their healthcare provider to be used and stored as they please. There are advantages to having electronic documents such as being able to duplicate documents easily and being able to store documents on a computer for later use.

Healthcare providers will typically have electronic documents available with your records in their digital database. If your provider does not give you access, you must inform them of your right to electronic records that you may need for a malpractice case or just want to view to have more information on your health or treatment. This includes transmitting copies of your electronics records to a law office you may be working with so that they have your information easily accessible to work on your case. The fee that is imposed for having a copy of your records electronically must not be greater than the hospital or healthcare providers labor costs in preparing copies of your records.

In 2009, the HIPAA regulations were modified by 42 USC § 17935 as part of the Health Information Technology for Economic and Clinical Health Act (“HITECH Act”):

(e) Access to Certain Information in Electronic Format. In applying section 164.524 of title 45, Code of Federal Regulations [HIPAA regulations], in the case that a covered entity uses or maintains an electronic health record with respect to protected health information of an individual

(1) the individual shall have a right to obtain from such covered entity a copy of such information in an electronic format and, if the individual chooses, to direct the covered entity to transmit such copy directly to an entity or person designated by the individual, provided that any such choice is clear, conspicuous, and specific; and

(3) notwithstanding paragraph (c)(4) of such section, any fee that the covered entity may impose for providing such individual with a copy of such information (or a summary or explanation of such information) if such copy (or summary or explanation) is in an electronic form shall not be greater than the entity’s labor costs in responding to the request for the copy (or summary or explanation).

The records should include, if applicable, their Hospital admission face sheet; ALL RADIOLOGY FILMS; Discharge summary; Admission history and physical; Progress notes; Orders; Physical Therapy Notes, Consultation; Lab values; Graphic vital signs; Anesthesia record; Operative reports and notes; Pathology reports; Recovery room; Nurses notes; Medication records; Outpatient records; Emergency room records; Special diagnostic tests; and Fetal strips.

Typically, an attorney will want an opportunity to review the records and potentially have an expert review the records prior to undertaking the representation.  In some cases, there can be thousands of pages of medical records that will need to be reviewed.

After the medical records have been gathered, a timeline or chronology is often the most helpful information to determine if medical malpractice has occurred.  As attorneys, we often hire consultants (such as nurses) to review the medical records and draft a timeline of what occurred including the important vital information about the patient at each critical point.

If you need assistance in gathering electronic medical records to use in a medical malpractice case you can give us a call at (505) 242-7200. If you need representation in a medical malpractice case be prepared to give us a summary of the case so that we can best assist you. The Davis Kelin Law Firm focuses heavily on medical malpractice case and it is one of our main areas of expertise in the personal injury field. We are Albuquerque’s Premier Personal Injury Law Firm and accept cases throughout all of New Mexico.