Records Not Contained in the Patient Record
A medical malpractice claim is based on an alleged injury to a patient, and the patient's medical records are needed to either prove or disprove the claim. However, the hospital record may not be the only source of information about the patient's treatment and condition. Documents may exist inside and outside of the hospital that contain valuable information but that were never made part of the patient's official hospital record, and a request for documents or a subpoena for the "medical record" may not result in a release of this information. Therefore, separate requests may be needed to unearth the documents maintained in different hospital departments.
Among the records that may not be included in the hospital record are the following:
Emergency Transport Records. Frequently, ambulance "run sheets" indicating a patient's treatment during transport are not part of the hospital record. If the patient has been transported by helicopter or interhospital air or ground transport, it is unlikely that the documents are included. This information may be very important in cases where the patient's condition prior to arrival and any efforts to resuscitate him or her prior to admission are crucial elements. There might also be transcriptions of audiotaped records of requests for transport that would include the time of the request, which would be crucial in determining whether a hospital was negligent in recognizing the seriousness of a patient's condition.
Kardex TM. A Kardex TM is a worksheet that consists of a form placed into a multiple flip-file folder. The Kardex TM holder will contain the Kardex TM sheets of many patients, and it centralizes important information about many patients for the convenience of the nurses. Often, there are two types of Kardex TMs - one for general patient information and one for medications. Technically, there should be nothing on the Kardex TM that is not found in the formal patient record, but it may contain crucial information as to the timely or untimely scheduling or administering of a certain diagnostic test. The Kardex TM may also contain instructions given to family members concerning the care of hospitalized patients, including the designation of a person to be notified under certain circumstances and resuscitation orders. Many hospitals discard the general Kardex TM after the patient has been discharged, but a request for its production may yield valuable information.
Autopsy Reports. Autopsy reports may consist of a provisional report and a final report, and the time lapse between the two depends on the number and type of tests performed. The final report may not be issued until more than six months after the death, and it is often not included in the hospital record. In addition, special care should be taken if specimens were sent to outside agencies for study because the reports from these agencies may take months to arrive and may never be placed in the patient's medical record.
Laboratory Testing. Although the results of all routine tests are generally found in the hospital record, there may be times when the proper procedure has not been followed by the hospital staff. There are instances when the time of testing and the reporting of a laboratory test are crucial to determine if there was any negligence in the healthcare provider's response to a patient's condition. If the hospital record does not contain adequate documentation of the time of a laboratory test, the same information may be obtained from the laboratory itself if it keeps a separate log or notebook.
Fetal Monitor Strips. These monitor readings are records of maternal contractions and fetal heart rate responses to the contractions. Many hospitals do not store these records, although some facilities microfilm the strips for easier maintenance. Even if they are kept by the hospital, they are often not included in the patient's medical record. In addition, there may be strips resulting from non-stress or contraction stress tests that are not included in the hospital record.
Hospital Logs. Many hospital departments keep separate records that are not included in the patient record. For example, there may be a delivery room log, an operating room log, or an emergency room log containing valuable patient and physician information.
Other Logs. In addition to the logs listed above, there may be hospital switchboard logs of events such as the calling of "codes" and the calling in of "on-call" personnel for emergency transport, disasters, emergency surgery, and obstetrics.
Technical Records and Studies. The original x-rays, CT scans, and other diagnostic images are generally maintained in the departments where they were taken while the reports made from the images are included in the patient record. Often, it is preferable for experts to review the original films rather than rely on reports. In addition, comprehensive records of procedures such as cardiac catheterization, angiography, cardiopulmonary bypass monitoring may not be part of the record.
Outpatient Records. Sometimes, records of outpatient treatment in clinics may be stored apart from inpatient records and must be separately requested.
Copyright 2008 LexisNexis, a division of Reed Elsevier Inc.
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