A healthcare provider whose negligence injures you may be held accountable through legal proceedings in New Jersey and required to compensate you for the resulting financial and emotional losses. However, you cannot obtain compensation without proof of medical malpractice. You must support your compensation demand with medical records that show the timing, cause, and nature of your injuries and the costs associated with diagnosing and treating them. They hold your medical history, treatment, and care of your current and past health problems, including medical notes, reports, summaries, and test results. Medical records are the backbone of your medical malpractice claim. Equally, you must know your rights to your health records, how to obtain them, and their pivotal role in proving your medical malpractice claim.
Fundamentals of HIPAA and Why it Matters
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) was enacted to ensure the exchange of patient health information is safeguarded for privacy protection. HIPAA’s federal legal standards for electronic health information transference and personal information security enable you to access and review your medical records.
Understanding Your Legal Rights Regarding Your Medical Records
You may request copies of your medical records from your healthcare provider and expect access to or copies of them within 30 days if you live in New Jersey. You can also amend your medical records for accuracy. Should your medical provider fail to comply with your rights under HIPAA, you write a written complaint to the U.S. Department of Health and Human Services or the Office for Civil Rights. However, you also have state resources to address violating your rights. You can file a complaint with the state agency that oversees your healthcare provider or sue them in state court for your records.
Entitlements and Permissions to Your Own or Someone Else’s Health Information
Under New Jersey law, you can get your health records from medical care providers. That means all documents that pertain to you. As a legal guardian, conservator, estate representative, or designee in a power of attorney, you can obtain records of those you have legal responsibility and care for.
When you are the guardian of a minor child, you may obtain their medical records. Likewise, when you are the legal conservator for an incapacitated individual, you have the legal right to obtain the records of the individual subject to the conservatorship. As an estate representative, you can get the records of the decedent. A power of attorney may also allow you to get medical records for the person who gave you authority to do so in the legal document.
Finally, you can obtain your minor child’s medical records when they are not confidential, meaning the procedures covered in the records do not require parental consent, a court orders the medical care, or the patient-provider relationship is confidential.
Key Information Contained in Medical Files
Your medical records contain all aspects of healthcare, from initial consultation to treatment and aftercare. Thus, they contain the notes from your initial visit with a doctor or clinic, including the reported symptoms, physical examination, and initial diagnosis. Before your initial consultation with a physician, you may have detailed your and your family’s medical history for illnesses, diseases, conditions, and surgeries. Those records are accessible as well.
If your healthcare treatment required hospitalization, hospital records and discharge reports that summarize the care you received at the hospital and home care instructions are in your records. Also, when your hospital stay includes surgery, your records will reflect the type of surgery and what was done. Finally, records include medical prescriptions for your condition or pain and lab test results that your doctor ordered were run by one or more labs are part of your healthcare records.
Notably, some records may not be produced due to confidentiality, such as psychotherapist notes or medical information that would endanger another’s life.
Various Methods to Attain Your Personal Health Records
You may already have some of your medical records, such as hospital discharge records, pharmaceutical receipts, and medical summary reports. You may also have kept document receipts regarding your injuries.
You can ask your healthcare provider directly for those you do not have. For example, you can get hospital records from the hospital, your doctor’s general practice, or a healthcare clinic. You can call ahead and find out how to get your records, whether the request must be in writing or you can go to the hospital and request them in person. Sometimes, you may be required to contact a third party that maintains the hospital records and follow their procedures. In other cases, your records may be accessible through a secure online platform reserved exclusively for patients.
If you have trouble, you can ask for an attorney’s help. When you face challenges from a healthcare provider, your attorney can get a court order to release your records. A subpoena orders the record holder to release the documents that you specify per your request. Also, when your attorney files a lawsuit on your behalf, you can obtain medical records from your providers through discovery requests, including demands to produce documents.
What Should be Included in the Medical Record?
You should request all medical records associated with your name and social security number and specify hospital, discharge, initial consultation, pharmaceutical, notes, summaries, lab test results, anesthesia, pathology, specialists, and surgical records. You may also identify the records by a time frame.
Value of Medical Records when Filing a Malpractice Lawsuit in New Jersey
Medical records may reveal the source of negligence by showing that a physician gave the wrong discharge instructions, incorrect medication or dosage, or made a mistake during an operation. When the records do not directly reveal an error, a medical expert may review them to discover where a physician or other healthcare professional went wrong. For example, given the patient’s prior health history, a medical expert may find something in the patient’s medical history that shows that a physician chose the wrong procedure or failed to act with the proper treatment when it was necessary.
Medical experts are often called to give an opinion on what caused a patient’s injuries or complications. For example, when an initial diagnosis is incorrect or treatment is delayed, a medical expert could attribute the delay to causing a disease to progress beyond treatment options or increase the extent of the treatment. Additionally, reviewing which tests were ordered and when could establish causation.
Medical records also document surgeries, treatments, medications, and healthcare visits over time to show the progress of a disease or the extent of injuries. For example, a simple surgery can turn near tragic when an anesthesiologist administers the wrong anesthesia or dosage or fails to prep the patient correctly, and the patient suffers brain damage or dies. The trail of who did what and when is in the medical records.
Post-hospitalization and continuing care needs are also revealed in the records through physician notes for further treatment and actual treatments over time. Records may reveal medical devices and apparatus for a patient with long-term disability due to injuries incurred under medical care. The full scope of your injuries and the long-term medical, rehabilitative, and other related healthcare needs associated with the damage done are all key aspects of your health records.
Our Legal Team can Use Your Medical Records to Your Advantage in a Malpractice Action
You can rely on our accomplished team of medical malpractice attorneys at Fronzuto Law Group when you need help getting your medical records to prove your medical malpractice case. Hospitals and billing companies may place you last on their list of jobs to complete when you request your documents. Still, our lawyers understand how to compel those legally obligated to give you your records to comply with your request informally or formally through the courts. Upon thoroughly reviewing your medical records, consulting with relevant medical experts, and carefully preparing your case, we will work tirelessly to obtain compensation for the injuries that you or someone you love suffered due to your healthcare provider’s negligence. Contact us for a free review of your case anytime at (973)-435-4551.
