Medical Records

Importance of MD Malpractice Medical Records

After you return the engagement documents, in the next phase in the process, we will order your MD malpractice medical records and analyze them when they arrive. The purpose is to determine if there is potential medical malpractice.

Medical records play a crucial role in healthcare as a comprehensive documentation of a patient’s medical history, diagnoses, treatments, and other relevant information. However, there’s a good chance that the medical records have much information you do not know. The medical staff only sometimes gives you vital information concerning your treatment. The medical staff often disappears and fails to address why a bad outcome happened. In addition, the medical records also include small details that would be impossible to convey in their entirety to the patient.

The MD malpractice medical records will be critical to a complete evaluation of the medical malpractice claim. The following is a description of some of the significant components of the medical records.

MD Malpractice Medical Records: Electronic Health Records (EHRs)

Electronic Health Records, commonly known as EHRs, are digital versions of a patient’s medical history. They contain a wide range of information, including demographics, medical diagnoses, medications, allergies, immunization records, laboratory test results, and more. EHRs are accessible across different healthcare settings, allowing authorized healthcare professionals to access and update the records as needed. This type of record promotes efficient communication and coordination among healthcare providers.

Admission – History & Physical

The admission records will have details about your arrival at the hospital, the physical complaints that you were having, and the condition you were in. These documents also contain the initial assessment and plan by the medical staff. These can be a crucial part of the overall records, especially if the case is for misdiagnosis.

The medical history record also provides a comprehensive overview of a patient’s past and current health conditions. It includes details such as previous illnesses, surgeries, allergies, family medical history, and lifestyle factors that may impact the patient’s health.

Orders & Progress Notes

Healthcare professionals create progress notes during each patient encounter. These notes document the details of the visit, including the reason for the visit, symptoms, physical examination findings, diagnoses, treatment plans, and any follow-up instructions. Progress notes serve as a chronological record of the patient’s healthcare journey.

The medical staff also documents the orders made during the treatment in this part of the medical records.

Operative Reports

Any surgeries or significant procedures will have an operative report. It is a narrative that describes the event from start to finish. These documents are particularly relevant in surgical error cases.

Medication Records

Medication records provide a comprehensive list of all the medications prescribed to a patient. This list includes the name of the drug, dosage, frequency, and duration of use.

Laboratory and Diagnostic Test Results

This type of record includes the results of various laboratory tests, such as blood tests, urine tests, imaging studies, and biopsies. These records provide valuable information about a patient’s physiological functions, organ health, and potential disease markers.

Discharge Summary

This document summarizes the entire hospital treatment. Reviewing this document to get an overview before deciding what specific records to read next is often good. The discharge summary also includes any recommendation for follow-up treatment, which can be a primary issue in a medical malpractice case.

Other relevant medical record components include consultation reports (notes of specialist doctors) and consent forms.

MD Malpractice Medical Records Examples

The following examples show how we use medical records to assess whether you have a Maryland medical malpractice case. The medical records should provide information on each of these points.

1. Misdiagnosis
   • Date and time you saw the first doctor.
   • Symptoms you had.
   • Doctor’s examination and misdiagnosis.
   • Date and time you saw the second doctor.
   • Symptoms you had when you saw the second doctor, including any worsening.
   • Second doctor’s examination and correct diagnosis.
   • Any treatment you received.
   • Permanent injuries that you now have as a result of the misdiagnosis.
2. Surgical Error
   • Symptoms you had.
   • Surgeon’s examination and diagnosis.
   • Surgeon’s operative procedure.
   • Complications during or after the surgery.
   • Permanent injuries that you now have from the surgery.

For a case involving the cost of medical records, read the blog post on Hollabaugh v. MRO.

The Kopec Law Firm is ready to review your Maryland medical malpractice medical records. To start this process for your case now, visit the free consultation page or video. Then contact the Kopec Law Firm at 800-604-0704 to speak directly with Attorney Mark Kopec. He is a top-rated Baltimore medical malpractice lawyer. The Kopec Law Firm is in Baltimore and pursues cases throughout Maryland and Washington, D.C.

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