Requests for Medical Records

Timothy R. Bone, President, MedMal Direct Insurance Company // May 19, 2012

More and more frequently when lawyers are requesting medical records in instances involving potential litigation, the involved physician often learns of the request only after the plaintiff’s lawsuit has been filed. This is not only true for hospitals, but for individual physician practices as well. In fact, in Florida it is part of the pre-suit requirements for the patient’s attorney to obtain a copy of the pertinent medical records from the doctor who is the potential defendant.

Over the years I have noticed an alarming trend for the physician to simply rely on the office staff to process this particular request for medical records without notifying the attending physician. Though there are many lawyers’ requests for medical records received in medical offices — and though not all indicate a lawsuit against the attending physician is just around the corner — I am absolutely sure that the attending physician would prefer to have notice of this lawyers’ request for medical records when the request involves a potential lawsuit against the attending physician.

LAWYERS’ REQUESTS FOR MEDICAL RECORDS

Issue: Releasing records to an attorney without notifying the attending physician about the inquiry.

Solution: Adopt the policy of joint notification of the administrator as well as the attending physician involved in the care of the patient about whom inquiries are made.

Review Procedure: 1. Review the list of record requests over a period of time to identify which have come from lawyers. 2. Review documentation in the involved charts – or in a log of entries of legal inquiries for medical records – indicating that the attending physician had been notified. 3. Regardless of existing documentation, contact a sample of the involved physician(s) to confirm that appropriate notification had actually been received.

Actions to Be Taken: 1. If all is in order, so notify the Medical Executive Committee and the medical staff at the next staff meeting. 2. If problems exist, devise a solution, implement it, and re-audit the issue and report the findings to the Medical Executive Committee and to the medical staff.

Added Point of Emphasis: In the office of certain medical specialties, a dozen lawyers’ requests for medical records are received every week; for example, in an office of an Orthopaedic Surgeon who handles work related injuries. In this situation, each attending physician must grant authority to the administrator or staff outlining specific parameters as to when the physician should be notified by the staff of lawyers’ medical records requests. In this environment, the physician will not need to be notified of every request; however, when the letter begins with something similar to “This law firm represents Jane Doe, John Doe and their minor children for a medical negligence claim …” then the attending physician/surgeon should be immediately notified. It is also especially important to note that significant cooperation between the hospital and the involved physician(s) can take place in bringing about effective arrangements to assure that justice will be served. Thus, when either party – be it the physician or the hospital – learns of potential litigation, each should notify the other so that a reasonable defense can be constructed.