Top Four Attorney Concerns About Medical Records Part 3: Certified Copies – Are They Complete?

By Tracy L. Liberatore Esq, PA

This is part three of a four part series and a continuation of my prior articles regarding attorney concerns and looks at the third item on the poll run by Pat Iyer; Certified copies-are they complete?

How Can You Tell?

A physician office or hospital sends you a copy of your client’s medical record and you wonder if it is the complete record. You ask for a certified copy to try and ensure you have the complete document. Supposedly a certified copy means someone compared the record to the original medical record and concluded every page was duplicated. So how can you tell if the record is still missing pages? What if those pages contain crucial information that would change your case, perhaps make or break your case?

Sometimes a hospital or physician’s office will insist the record is complete, yet it is missing obvious entire sections of the record.

Other times, however, the missing data is buried in thousands of pages of data that has been provided. Sometimes there are duplicate pages provided, and you wonder if this was done on purpose to cause you to rush through the documents and perhaps overlook what is missing. Perhaps the records are printed in such a way that it is difficult to tell if one page is the continuation of the prior page.

Don’t Let This Happen To You!

I have seen in the past where there is a critical event in question, yet there is no documentation in the records provided surrounding that timeframe. It may only be a matter of hours, yet there is nothing in the record provided to suggest orders given, medication administered etc. How is it possible for a patient to decompensate and even code without there being something documented in the chart at some point about what happened? The Medication Administration Record (MAR) should at least reflect what medication was given and when.

Unfortunately, the untrained eye would not notice this important and critical information was missing. What if the wrong medication was ordered and it caused the patient, your client, to decompensate? What if this is the causal connection you are looking for, but there is no documentation to show this because the information was (purposefully?) not included in the copy sent to your office? This is evidence of how this information can make or break your case.

If the information is missing, more likely than not, it is something that would be of use to your case. You need this information to get a complete picture of what happened.

Help Is Available!

This is where a medical legal consultant can help! We are trained professionals who look at records and know when information is missing because we know how the medical system works. We know certain things are required to be documented. We can locate the event, and look to see that all the proper associated documentation is available in the records you have been given.

Don’t miss an opportunity to capitalize on a winning case because you don’t have all the records! Don’t miss an opportunity to settle because you missed a medical error due to a cover up that resulted in a failure for you to obtain the entire record! Help is only a phone call away!

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