When it comes to the effective prosecution of nursing home negligence cases or medical malplractice cases, medical records are a crucial piece of the puzzle in determining the essentials: who, what, where– and sometimes why.
Pursuant to the following federal regulations, nursing homes must create, maintain and release medical information to patients or their authorized representatives:
- F-514 §483.75(l)(1)&(5) – Maintaining/Content of Clinical Records
- F-515 §483.75(l)(2) – Retention of Clinical Records
- F-516 §483.20(f)(5); §483.75(l)(3) – Release of Resident Identifiable Information / Safeguarding Clinical Record Information
Obtaining copies of medical records from nursing nursing homes can become quite complicated in situations where a patient becomes disabled or dies. A maze of privacy laws and probate laws, can rapidly make a (seemingly) straightforward process difficult.
A prime example of the difficulty some families experience when attempting to obtain nursing home records for their loved one caught my attention out of Texas. After unsuccessfully requesting the medical chart directly from the facility, the family of the deceased nursing home patient was forced to seek court involvement to get the facility to turnover the their mother’s records.
In addition to ordering the nursing home to provide the family with access to the records, the court similarly granted a temporary restraining order (referred to as a TRO) that requires the facility to “produce all healthcare and medical records, correspondence, memos, incident reports, photographs, investigative documents, witness statements and other documentation” related to the deceased patient.
I surely can sympathize with this families frustration stemming from their difficulty getting copies of their loved ones medical records. While I understand that facilities need to comply with privacy laws, I find many facilities use delay and deny tactics when it comes to providing medical charts when the requests are made by people with authority to do so and utilizing HIPPA compliant forms.
Particularly in circumstances where a family may suspect that the facility was negligent in the care of their loved one, I always encourage families to request copies of the medical chart as soon as feasible. Disturbingly, I have worked on a number of nursing home abuse lawsuits where, the records provided to the family (and assumingly never reviewed by a lawyer defending the facility) differ significantly from the copies of records provided to me in the course of litigation.
Mysteriously, entries seem to have a way of either getting omitted to added to the chart that I receive in a way to make the care provided seemingly much better than it actually was. While most facilities know better than to alter a legal document, in circumstances where this does occur, I do my best demonstrate the descrepancies to staff during their depositions. When the ‘inconsistencies’ come to light, many facilities recognize the probable fallout from their acts and may request our presence at a settlement conference.
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