Medical records include physician and nursing notes, orders, medication administration records, diagnostic results, operative and pathology reports, discharge summaries, and billing documentation.
They are obtained through patient authorization, subpoena with the protections HIPAA requires, or discovery, and are typically admitted under the business records exception.
Alternative Names:
Patient Records, Medical Chart
Why it Matters?
Records are simultaneously the plaintiff's proof of damages and the defense's best source of contradiction, since patients describe their history and limitations to providers differently than they do in litigation. The recurring defense findings are prior complaints of the same condition, activity levels inconsistent with claimed disability, and gaps in treatment. Completeness matters more than volume, because a production missing a prior treater is where the useful material usually sits.
Frequently Confused with
Related terms
Frequently asked questions
How are medical records obtained in litigation?
What do defense reviewers look for first?
