Medical Records: A Lawyer's Guide to Records Retrieval

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Medical records form the cornerstone of a strong personal injury case. After all, how would a personal injury plaintiff prove their case without evidence of their injuries, treatment, and recovery? 

But before you assemble medical evidence to develop a winning personal injury case, you have to think about medical records retrieval. And, with countless files and daily deadlines, sometimes the time and effort involved in gathering medical records can feel daunting. 

In this blog post, we’ll discuss the importance of medical records in personal injury and steps personal injury lawyers can take to optimize their medical records retrieval process—including the must-have software that makes medical records retrieval easier than ever. 

Understanding medical records 

Personal injury claims require many different types of evidence. From employment records to expense receipts, there’s a lot to keep track of. But where do medical records fit into this equation? 

What are medical records? 

There are several different types of medical records you’ll come across as a personal injury lawyer, each serving a different purpose. The most common types include: 

  • Physician’s notes: These records contain detailed information about a patient’s symptoms, diagnosis, and prescribed treatments. They often include notes on the patient’s progress and any changes in their condition. 
  • Laboratory reports: These records include the results of various tests, such as imaging scans or blood tests. They provide objective data that can help assess a patient’s condition. 
  • Surgical reports: These records document the details of any surgeries or procedures performed on a patient, including pre-operative assessments, operative notes, and post-operative care. 
  • Progress notes: These records are usually written by nurses or other healthcare professionals and document the patient’s daily progress, including vital signs, medications administered, and any changes in their condition. 

Medical reccords.

The importance of medical records in legal cases

Medical records serve as concrete evidence of a personal injury plaintiff’s injuries, treatment, and recovery, providing a factual account of a client’s medical journey following an accident. They can also help establish causation (i.e., that the accident caused or contributed to the plaintiff’s injuries), demonstrate the extent of damages, and otherwise form the backbone of a lawyer’s arguments. 

Medical records aren’t just useful for the plaintiff and their personal injury lawyer, though. They can also be used by defense counsel and other stakeholders to disprove the plaintiff’s claim. For example, if the plaintiff claims at their deposition that they have not recovered from their accident-related injuries, yet their physician’s notes suggest that they are recovering well, that information can be very helpful to the “other side”. 

Legal procedures for medical records retrieval

You now understand the importance of medical records—but what about medical records retrieval? Lawyers must follow specific rules and procedures for medical records retrieval—and defense lawyers and other stakeholders must follow their own rules when requesting medical records from the plaintiff. 

Medical records retrieval for personal injury lawyers

To request medical records for a plaintiff, you’ll typically need to obtain the client’s written consent and submit a written request to the healthcare provider or facility that possesses the records. Your request should include relevant details, like the patient’s name, time period during which you are requesting records, and other identifying information. Some providers may have specific forms or online portals for record requests, so be sure to follow their instructions. 

Medical records retrieval via subpoena

In some cases, lawyers may need to retrieve medical records by subpoena. For example, a personal injury lawyer might properly request medical records from a medical professional. For any number of reasons, that medical professional may ignore or choose not to respond to the request. 

Likewise, defense lawyers may attempt to request medical records by subpoena if they are experiencing difficulty obtaining them from the plaintiff’s lawyer. 

HIPAA compliance and protecting patient privacy 

HIPAA, a federal law, requires healthcare providers and “business associates” to protect PHI from inadvertent disclosure. Since law firms are considered business associates, they must comply with HIPAA when handling PHI on behalf of their clients, especially once medical records are retrieved, and that information is being stored by the law firm.

Using the right medical records management software can help your firm comply with HIPAA’s requirements. For example, Clio has completed an internal HIPAA attestation examination by reviewing and meeting the 658 standards in StandardFusion, a risk management platform, to measure and document our HIPAA compliance. Clio’s data security standards adhere to industry best practices for client data management and meet the technical standards required for business associates under HIPAA. 

Challenges and solutions in medical records retrieval

Even if you have your client’s consent to obtain their medical records, some common obstacles can arise during the medical record retrieval process. We’ll outline some of those challenges—along with potential solutions—below. 

Addressing incomplete or missing medical records

A woman looking at incomplete records.

One of the most significant challenges lawyers face when retrieving medical records is dealing with incomplete or missing medical records. For example, a medical professional might have poor record-keeping practices (meaning that some of the medical records may be unavailable), or they may not understand the nature of your request. While non-existent records are a separate issue entirely, requiring strategic decisions on the part of the personal injury lawyer, lawyers can maximize their chances of having a medical professional successfully fulfill their request by providing clear and thorough instructions in their request. 

They might also consider working with a reliable medical records retrieval service, which can streamline the process and ensure all necessary records are obtained. These services have expertise in locating, retrieving, and organizing medical records, saving lawyers valuable time and effort. 

Navigating state-specific rules and regulations

Remember that each state has its own rules and regulations regarding the retrieval of medical records. Lawyers must familiarize themselves with these requirements to ensure they are compliant. For example, some states may have specific forms or procedures that need to be followed when requesting records, while others may have restrictions on the types of records that lawyers can access. Staying updated with these regulations and seeking guidance from experts in medical records retrieval (when appropriate) can help lawyers navigate this challenge effectively. 

Overcoming barriers to timely record retrieval 

Not staying on top of your medical records requests can create a variety of challenges during legal proceedings. At best, delays in obtaining medical records might be frustrating or cause unneeded stress as you scramble to request records. At worst, these delays can result in missed deadlines (for example, getting records to a medical expert preparing a report for trial) or missed opportunities to strengthen your client’s case. 

How do you stay on top of your medical record retrieval? Leveraging technology solutions that simplify—and even automate—the medical record retrieval process can significantly reduce turnaround times and ensure timely access to essential records.

Efficient retrieval of medical records

Knowing how to retrieve medical records is just one piece of the puzzle—retrieving them efficiently is an entirely different matter. By implementing effective strategies and harnessing technology, solicitors can streamline the process of obtaining medical records, saving time and improving the overall efficiency of their practice. 

Here are some tips for organizing and managing medical records:

Establish a consistent filing system

If you don’t already have a system for organizing your medical records on each file, get one now! Create a consistent method for organizing medical records, such as categorizing by medical professional, type of evidence, or date. This will make it easier to locate specific records when you need them. 

With Clio for Personal Injury, you can organize medical records by provider, track missing information, and set follow-up reminders to contact medical professionals about outstanding records all in one place. 

Digitize records

Even if you have a great paper filing system, sifting through paper records is time-consuming and inefficient—to say nothing of the risk of loss or damage. Medical records software lets you digitally search by keywords (using the document’s title, metadata, or text) to find and retrieve medical records in seconds. 

Implement document management software

Invest in a reliable document management system that allows you to store, organize, and retrieve medical records efficiently. Look for features like advanced search capabilities and secure access controls, like those offered by Clio

Working with medical record retrieval services

Some lawyers may want to consider partnering with a specialized medical record retrieval service. These companies typically have established relationships with healthcare providers and expertise in navigating the complexities of medical record retrieval. 

If you choose to go this route, be sure to choose a reputable record retrieval service that ensures the accuracy and completeness of the records obtained. This reduces the risk of missing critical information that could impact your case. 

Using medical records in court

So, now you’ve got the medical records—but how can you use them for your personal injury claim? These documents will form a critical part of the claim, providing the evidentiary backbone of your client’s claims. 

Admissibility of medical records as evidence

The admissibility of medical records as evidence in court is generally determined by their relevance, authenticity, and trustworthiness. To be admissible, medical records must be deemed relevant to the case at hand and must meet the requirements for authentication, ensuring their accuracy and integrity. 

Presenting and analyzing medical records in evidence

Once medical records are admitted as evidence, presenting and analyzing them effectively becomes crucial. Organizing the records in a logical and coherent manner can help present a compelling narrative to the judge (or jury). 

Here, technology can help lawyers present and analyze medical records efficiently at trial. For example, using Bates numbering to sequentially number record pages can make it easier for all parties (including opposing counsel and the court) to follow your arguments.  

Expert testimony and medical record interpretation

A doctor giving testimony.

In many personal injury cases, lawyers will call on experts to prepare reports and provide testimony to interpret the plaintiff’s medical records. These experts can provide professional opinions based on their expertise and knowledge while helping to clarify medical terminology, establish causation, or challenge opposing expert opinions. 

Final thoughts on medical records retrieval 

With the right medical records software, lawyers can save time on medical records retrieval while setting their medical evidence up to be presented in the best light. And for medical records management, consider Clio’s legal document management software, which allows you to work securely and access your documents from anywhere while benefiting from the flexibility of unlimited document storage, advanced document search, e-signatures, and more. 

Finally, for personal injury lawyers, Clio’s Personal Injury Add-On makes it easier than ever to stay on top of medical records retrieval. With this software, you can manage medical records, damages, and settlements all in one place, so you and your team can access every case detail at a glance. 

Note: The information in this article applies only to US practices. This post is provided for informational purposes only. It does not constitute legal, business, or accounting advice.

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