Medical records are one of the most important pieces of evidence in personal injury, medical malpractice, and nursing home abuse cases. These records provide a detailed account of a patient's medical history, treatment, and the decisions made by healthcare providers. As a result, in any lawsuit, they tell the story of the harm that was done to the patient. Understanding the role of medical records, the rights patients have to access them, and the potential inaccuracies that can arise is essential for anyone pursuing a legal claim related to medical care.
The Role of Medical Records in Injury and Malpractice Cases
Medical records serve as the foundation for any legal claim involving injuries or medical negligence. These documents can:
- Establish a Timeline of Events: Medical records provide a chronological history of treatment, which can help establish when an injury occurred and whether appropriate medical care was provided.
- Document Symptoms and Treatment: Records reflect the patient's symptoms, diagnoses, treatments, medications, and responses to care, which can be crucial for proving causation in a malpractice case.
- Support or Contradict Claims of Negligence: If a healthcare provider deviated from the accepted standard of care, medical records may contain evidence of errors, omissions, or inconsistencies in treatment.
- Assist Expert Witnesses: Medical experts rely on these records to analyze whether a provider's actions were appropriate or fell below the expected standard of care.
Your Right to Access Medical Records in Missouri
Under Missouri law, patients have a legal right to obtain copies of their medical records. The Missouri Revised Statutes (§ 191.227) establish that:
- Healthcare providers must provide patients with copies of their records upon written request.
- Providers can charge a reasonable fee for copying records but must comply with state limits on these charges.
- Patients generally have the right to request records for themselves or authorize another party, such as an attorney, to obtain them on their behalf.
- Requests should be fulfilled within a reasonable timeframe, typically within 30 days.
Having access to these records is essential when preparing a legal claim. If a provider refuses to release records, patients may have legal remedies to enforce their rights including the filing of a lawsuit for damages. If you are considering pursuing a personal injury claim, and especially one for medical malpractice, promptly securing a copy of your records can be very important.
Why Reviewing Medical Records for Accuracy Is Important
Errors in medical records can have serious consequences, both for ongoing medical care and legal cases. Unfortunately, while electronic medical record software was intended to improve documentation, it does not always have this effect. Some common reasons that inaccuracies occur include:
- Electronic Health Record (EHR) Templates and Dropdown Menus: Many healthcare providers use electronic systems that rely on pre-filled templates or dropdown selections. This can lead to incorrect information being added to a patient's chart, especially if a provider selects the wrong option by mistake.
- Copy-and-Paste Practices: Some providers copy and paste previous notes into new records, leading to outdated or inaccurate information being perpetuated.
- Incomplete or Missing Information: A provider may fail to document a key symptom, test result, or treatment decision, making it harder to establish what actually occurred.
What You Can Do If You Find Errors in Your Records
If you identify errors in your medical records, you have the right to request a correction. Under the Health Insurance Portability and Accountability Act (HIPAA), patients can submit a written request to their healthcare provider to amend inaccurate information. For many providers, it may be possible to submit this request through a patient portal such as MyChart. While providers are not required to make every requested change, they must review and respond to requests within a specific timeframe.
Conclusion
Medical records are a critical component of any personal injury, medical malpractice, or nursing home case. Understanding your right to access these records and ensuring their accuracy can play a key role in supporting a legal claim. If you suspect that medical negligence has occurred or you need assistance obtaining and reviewing your records, consulting an experienced attorney can help ensure that your rights are protected and that you have the best possible evidence for your case.