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Family Seeks Court Involvement To Obtain Copies Of Medical Records From Nursing Home

medical-chartWhen 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.

For more information on nursing homes in Texas look here. For laws related to Texas nursing homes, look here.

Related Nursing Homes Abuse Blog Entries:

How Accurate Are Medical Records From Nursing Homes?

Nursing Home Settles Lawsuit After Fraudulent Records Discovered

How do I get a copy of medical records from a nursing home?

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  • “Annabelle”

    Thank you for posting this. As you may surmise, I’m staying anonymous and not giving my real name, as my Mother died in a rehab unit in Indiana on Oct.2, and it looks as if this will go into a lawsuit.
    I posted the jist of Mom’s account under a blog you wrote regarding dehydration, so I’ll not repeat the whole tragic story here.
    I have been stonewalled, too, in trying to get Mom’s records. The RN I spoke with the day after Mom unexpectedly died first told me I’d be allowed to get her records, but when push came to shove, I was not allowed to get her records. As you mentioned above, I got told about HIPPA, etc., then was told I’d be better off not knowing.
    I have a lawyer looking into Mom’s case and am praying that this will go into a lawsuit, etc. I fully expected to bring my Mother back home. The investigation has not progressed to the point where I have signed any papers yet to officially hire the lawyer, but I’m hoping we’ll reach that stage very soon.
    Thank you so much for your blog. It’s very educational. May God bless you for your work. Unfortunately, it’s very needed.

  • Hi Annabelle-
    Again, my condolences to you and your family for your loss. Your experience obtaining (or at least attempting) medical records is the source of endless frustration for families who are trying to simply get answers to basic questions that they have. Frankly, I’ve come to the conclusion that many facilities simply fail to educate their employees about what is required for a family member to obtain a patient’s medical chart. Hopefully, state legislatures will address this issue and make it easier for families to get basic medical information regarding the care of their loved one without the necessity of obtaining a court order.
    I wish you well as you begin the process of learning about your mother’s care. Jonathan

  • Annabelle

    Thank you, Jonathan, for your comment. I’m keenly interested in your nursing home blogs, and you’re doing a great service for those of us struggling to get answers for what happened or is happening with our loved ones in these “care” facilities.
    For now, I backed off trying to get Mom’s records because a lawyer is doing a preliminary case evaluation. The attorney commented it that it looks like a tough case, but I’m hopeful and literally praying we can go forward with it. The attorney requested a copy of Mom’s death certificate, and I’m told I’ll hear something this next week.
    Thank you again for what you do, and have a great Thanksgiving.

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