Medical and Dental Records:
What you need to know and how to understand what you have.

Types of Records

Medical and Dental Office Records:

1. Notes made each time the patient was seen
2. Records of telephone conversations with the patient
3. Reports of laboratory tests and x-rays made in the office or somewhere else
4. Copies of x-rays made in the office
5. Copies of photographs made in the office
6. Copies of important parts of the patient’s hospital chart, if applicable
7. Copies of insurance claims
8. Copies of correspondence with other doctors regarding the patient

Hospital Records

A. Primary

The following records should be considered a must, if applicable to your case.

1.   Face sheet
2.   Emergency room record, if applicable
3.   History and Physical examination
4.   Doctor’s admission and progress notes
5.   Reports of consultations with other physicians
6.   Anesthesia records, including the anesthetist’s preoperative consultation and
examination
7.   Operative reports
8.   Labor and delivery records, if applicable
9.   Examination of newborn infant
10. Recovery room and/or ICU records
11. Surgical Pathology report
12. Reports of x-rays, EKG, fetal monitoring strips, and any other special
diagnostic tests that were performed
13. Copies of x-rays or other diagnostic tests that were preserved on film or CD
14. Graphic chart (temperature, pulse, blood pressure, etc.)
15. Incident and accident reports, if the patient fell or was injured
16. Autopsy protocol, if applicable

B. Secondary:

These records may comprise as much as 80% of a hospital chart.  Request only those pages that contain pertinent information.

1. Routine laboratory reports
2. Nursing notes
3. Physicians’ orders
4. Medication records
5. Consents to treatment or surgery, unless lack of informed consent is part of your    client’s complaint

C. Limited value:

Do not order these records, unless they are pertinent to your case.

1. Dietary notes
2. Input and output records
3. Nurses’ worksheets
4. Physiotherapy, respiratory therapy, counseling, etc.
5. Correspondence regarding your client’s case
6. Financial records
7. Receipts of valuables

Hospital - Internal Records:

These are records the hospital keeps, and very little is ever heard about them.  In certain states, some of these records are protected by law and not available.

1. Operating Room Log

This is a record kept by the head operating room nurse.  It records everything that went on and who was in the OR, including the pre and postoperative diagnoses and the names of all nurses, anesthetists, and personnel who went in and out of the room.  From this log, you can learn what actually happened (not the doctor’s version as found in the operative report) and the names of witnesses, who can give a true account of events.

2. Morbidity and Mortality Conference

Extreme problems with a patient or unexpected death may result in the medical staff convening a Morbidity and Mortality Conference.  Here doctors speak out frankly about what was done wrong and ways to prevent it from occurring in the future.   Frequently, the minutes of these meetings are not available, even with a court order.

3. Tissue Committee

This committee reviews surgical pathology reports on specimens removed during surgery to check on the necessity of the operation.  Often, this committee will find the doctor’s diagnosis incorrect, and the surgery should not have been performed.

4. Infection Committee

This group monitors infections occurring within the hospital and discusses methods of prevention.  If the doctors on this committee are critical of treatment your client received, it will greatly enhance your case.

5. Tumor Committee

Monitoring of diagnoses and treatment of cancer patients is the primary focus of this group.  If there is a question as to timeliness or accuracy of diagnosis by the treating physician, the records of this committee could be beneficial.

6. Medical Records Committee

The Joint Commission on Accreditation of Hospitals has established strict rules and requirements on how a hospital is to keep, maintain, and preserve records safely.  Periodic reviews of medical charts for deficiencies, inconsistencies, and alterations are conducted by this group.

7. Credentials Committee

This committee reviews the qualifications of all doctors, who apply for staff privileges.  While hospitals are not generally liable for what an independent doctor does in each case, the hospital does have an obligation to be sure the doctor is qualified to exercise the privileges accorded him or her and to check his or her performance periodically.  If the records of the Credentials Committee indicate the doctor was not qualified to treat your client, the hospital may also be liable for the injuries sustained by your client.

8. Quality Assurance Committee

Once a doctor is admitted to the hospital staff, his or her performance is monitored.  If your client was a victim of malpractice, it can be assumed, the case was discussed by this committee.  You may also find this doctor was in trouble with the credentials committee before, for the same type of malpractice.

9. Medical Staff/Department Meetings

In smaller hospitals, the medical staff meets periodically to discuss cases.  In larger hospitals, departmental meetings are held for the same purpose.  In either case, minutes are written and maintained as permanent records.

These are only a few of the many internal hospital records, which may contain valuable information.  In order to encourage hospital staffs to improve patient care, and to protect doctors who serve on committees from reprisal, most states have passed laws making some of these internal records secret.  Laws vary from state to state.  In some states, you cannot obtain access to them, for any reason.  In other states, some or all of them may be available; if you can convince a Judge they contain information essential to your case.