Medical records are comprehensive documents detailing a patient’s medical history, diagnoses, treatments, and other relevant information. In medical malpractice cases, these records can serve as crucial evidence to support a patient’s claim. Yet, many patients are often uncertain about how to access these vital documents.
This article offers insights into the legal rights and practical steps patients can take to obtain their medical records, ultimately aiding them in building a compelling case against potential medical malpractice.
Medical Records as Confidential Documents
Medical records are inherently confidential, and patients have exclusive access rights. Canada has robust privacy laws that protect individuals’ health information. Patients, parents, guardians, or representatives receive access.
The Role of Medical Records in Birth Injury Claims
Given the unique circumstances surrounding childbirth, medical records play a pivotal role in understanding the events leading to and during the birth process.
From prenatal care to labour, delivery, and postnatal care, these documents detail an account of the events. Together, they contribute to a comprehensive case by offering objective evidence of the events leading to the birth injury.
Critical Information in Medical Records
Medical records extend beyond handwritten notes and consultation reports. Diagnostic imaging, fetal heart monitoring records, and pathology slides are integral components, often crucial in investigating medical malpractice claims. It’s imperative to recognize that a child born under medical care will possess a separate medical record from the mother.
Obtaining Medical Records: A Step-by-Step Guide for Patients
Here’s a general guide to help you obtain medical records for a potential medical malpractice claim:
Identify the Healthcare Provider
Determine which healthcare provider or facility has the relevant medical records. It could include hospitals, clinics, obstetricians, midwives, or other healthcare professionals involved in prenatal care, labour, and delivery.
Initiate the Request
Patients or their legal representatives must provide written authorization and consent to obtain medical records. Your lawyer can help you draft the necessary documents. Write a formal request for medical records, including the specific time or incidents you are interested in.
Address the request to the custodian of records at the healthcare institution. You may need to use a specific form provided by the institution or your lawyer.
Understand Privacy Laws
Familiarize yourself with federal and provincial privacy laws, like the Personal Information Protection and Electronic Documents Act (PIPEDA), and the national or provincial health information protection legislation. Ensure that your request complies with these laws.
Pay Any Required Fees
Securing a copy of your medical records is not without a financial implication. Charges vary among providers, and opting for electronic records to mitigate additional costs is advisable. Customers can send concerns about charges through a complaint to the Information and Privacy Commissioner of Ontario (IPC).
Legal Proceedings
Once you receive the medical records, carefully review them with your lawyer. Based on their advice and the information in the medical records, decide whether to proceed with filing a medical malpractice claim. Your lawyer will guide you through the legal process, including serving notice to the defendant and filing necessary court documents.
Accessing Medical Records for Children
In cases involving minors, specific individuals, including parents and legal guardians, are authorized to request medical records under PHIPA. Understanding these nuances is crucial when pursuing claims related to children.
Patients aged 14 or older have the fundamental right to access their medical records. They also possess the authority to authorize or deny access to others. It marks a crucial age where minors can independently decide about their healthcare and limit parental access to their medical history.
How Long Are Medical Records Retained?
Medical professionals must follow provincial or territorial laws on retaining clinical records. The CMPA advises keeping medical records for at least ten years (16 years in British Columbia) from the last entry or, for minors, ten years (16 years in British Columbia) from reaching the age of majority.
It applies to obstetrical care records kept for at least ten years from when the infant reaches or would have reached the age of majority. These retention periods are crucial for legal defence, as medical records are vital evidence in medical-legal issues.
Records for Deceased Persons
When someone dies, their heirs and family can access their medical records with limited information under certain conditions. Heirs, in particular, must substantiate their status with proof and submit a detailed request justifying their need. It might be from reasons like pursuing a medical malpractice lawsuit against a healthcare facility.
Timelines for Obtaining Medical Records
Provincial or territorial laws related to protecting personal health information govern response time. Ontario’s Personal Health Information Protection Act (PHIPA) stipulates the 30-day timeframe.
Seek Legal Assistance If Necessary
Seeking legal assistance is advisable if you encounter challenges getting medical records or believe your request is unduly delayed. A lawyer experienced in medical malpractice can guide you through the process and advocate on your behalf.
Medical Malpractice Case Evaluation
Once the necessary medical records are in hand, a birth injury lawyer conducts an examination, seeking essential information to build a comprehensive case.
Timeline of Events
A chronological record of events in medical records is valuable for assessing the sequence of medical care. This timeline helps determine if there were deviations from standard practices.
Identification of the Circumstances Leading to Medical Care
The birth injury lawyer scrutinizes the records, focusing on specifics that led you under the healthcare provider’s care. It involves understanding the circumstances that initiated the medical care and laying the foundation for the legal evaluation.
Assessment of Harm and Its Extent
Examining the records delves into indications of harm and its extent. The lawyer identifies details highlighting the impact on your well-being, forming a crucial basis for determining the damage’s severity.
Detecting Alterations or Gaps in Records
A critical part of a review involves identifying any signs of tampering, changes, or gaps in the medical records. It includes assessing completeness and ensuring that vital information isn’t missing, providing a comprehensive understanding of your medical history.
Expert Witness Support
Medical negligence lawyers rely on medical records to consult with experts who can analyze the provided care and testify about deviations from the standard of care, causation, and the resulting damages.
Seeking Guidance from a Birth Injury Lawyer at Sommers Roth & Elmaleh
If you or your child has suffered harm or trauma due to medical errors, the seasoned birth injury lawyers at Sommers Roth & Elmaleh are here to guide you through the process. We can obtain your medical records and pursue the justice you deserve.
Our commitment centers around championing the rights of individuals, particularly infants, who have endured birth injuries due to medical or nursing negligence.
Call Sommers Roth & Elmaleh at 1-844-777-7372 for a free consultation, or contact us here.