What Is Included in Medical Records?

A medical record is a documented account of an individual’s medical history, which can be information that can make or break certain legal cases.

Most individuals will have unique medical information from multiple providers as a single accident and injury could result in separate treatment and billing records for emergency response, admitting hospitals, surgeons, physical therapists, and more. 

Let’s take a look at what patient information is included in medical records and how you can use them to help prepare your cases.

Information Included in Medical Records

Before your attorney request for medical records, you should be aware that the information supplied might not be the same across every individual’s record. Patient records don’t always include every pertinent detail exchanged between patients and care providers, so it’s important to know what medical information you can expect, and which details you might need to dig further for. 

Typical medical records include: ¹

• Patient identification, contact information, and date of birth
• Billing and health insurance details 
• List of current and chronic ailments and diagnoses 
• Current medications list with dosage
• Documented allergies and sensitivities 
• Immunization records including past dates and outstanding needs

Depending on the detail requested and the healthcare provider, records may also include: 

• Treatment regimens for current or past diagnoses
• Past surgical and hospitalization procedures
• Medical tests, lab results and their findings (blood panels, X-rays, endoscopy, etc.)
• Provider notes and/or patient instructions following exams, visits, and consultations
• Statistics such as height, weight, and blood pressure on a set date or graphed over time
• Patient sexual orientation and gender identity

How Are Medical Records Used?

After going through the medical record retrieval process, these records may be entered as evidence or used as part of research and data collection in preparation for legal proceedings. They can assist in proving: 

• Evidence of injury – Medical records testify to the severity, nature, and treatment of an injury or illness. They testify to timing in terms of evaluation and diagnosis along with progress notes over time. 

• Cause of injury – Experts depend on patient records to conclude whether an assault, environmental factor, or malpractice can be held to be the cause of a condition or injury. They may also be used to corroborate the type of assaulting weapon and details about how an event played out or where it occurred.

• Impact of injury – In addition to the facts, some visual elements of medical records, such as X-rays, brain scans, or photographs, can help communicate the level of damage and pain suffered. This can also be conveyed by comparing before-and-after visuals or details that illustrate the difference in the plaintiff’s physical state and quality of life.

• Medical competence – In a malpractice suit, original medical records are critical to proving incompetence or negligence. Expert witnesses review healthcare provider notes and prescribed treatment, and their response to lab results and patient presentation, to determine if reasonable patient care was offered.

• Medical ethics violations – Healthcare providers who breach medical ethics can be pursued in criminal or civil court with medical records proving that they breached ethical codes. This may include sexual misconduct with patients, prescribing opioids for nonmedical use, recommending or performing unnecessary procedures, failing to provide the information required for proper care decisions, or disclosing confidential information without consent.

• Billing fraud – Fraudulent billing practices may fall under both criminal and civil, or state and federal, realms. Billing fraud can mean double-billing multiple insurance entities (like Medicare and Medicaid) for the same procedure, billing for services never provided, upcoding to bill for a higher-cost service, adding unnecessary services to a patient’s treatment plan, and the use of bribes or kickbacks for referrals or prescriptions.

Remaining HIPAA Compliant

The access and confidentiality of medical records are protected under the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA). HIPAA compliance for law firms ensures these medical and legal documents are only available to the patient, the patient’s legal representative, and the treating medical team.

The HIPAA Privacy Rule does, however, allow for the disclosure of protected health information (PHI) without the patient’s consent if the provider is compelled by a valid subpoena. ² 

Regardless of who you represent or how you obtain it, a legal team taking receipt of protected health information should: 

• Maintain strict security measures for transmission and storage
• Limit access only to authorized personnel
• Ensure all individuals who access PHI understand and comply with security policies

Get Your Case Records in Order with U.S. Legal Support

Now that you know what is included in medical records, what other steps do you need to take to prepare for your case? Accurate deposition and key meeting transcripts are equally critical to the successful outcome of any injury- or medicine-related lawsuit or criminal case. 

U.S. Legal Support can quickly and securely provide both medical record retrieval and court reporting transcription services. We’ve supported businesses such as attorneys, law firms, and other organizations since 1996 through our network of more than 5,000 court reporters and transcriptionists across the country. 

Contact us today to learn more about our legal support services.

Sources: 

1. HealthIt. Learn How to Get Your Health Record. https://www.healthit.gov/how-to-get-your-health-record/
2. U.S. Department of Health and Human Services. Court Orders and Subpoenas. https://www.hhs.gov/hipaa/for-individuals/court-orders-subpoenas/index.html

Julie Feller

Julie Feller is the Head of Marketing at U.S. Legal Support. Prior to U.S. Legal Support, Julie worked at Abacus Data Systems (now Caret Legal) providing legal technology platforms and services to legal professionals across the country.