Yes, and in many cases you should insist upon an “original chart review”.

Why is it important to review the original medical records?

What is an “originl chart review” and why should you care? An original chart review is an inspection of the actual medical records, instead of a photocopy. Why does an original chart review make a difference? Doctors will rarely, if ever, send you “all” of the medical records even when you request your complete medical records. The office notes of each visit are usually copied and mailed to you, but nothing else. Therein lies the problem! In most cases, the doctor’s office will not send you copies of lab results, results of imaging studies, scripts for medications, etc.

It is impossible to evaluate a medical malpractice case within ALL of the medical records and you cannot rely upon your doctor’s office to send you all of your medical records. So what do you do? Insist upon an original chart review at the doctor’s office! The inspection of your original chart at the doctor’s office or hospital is critically important.

What do you do if the doctor refuses to let you see the original medical records?

Now for the hard part: How do you schedule an original chart review? Many hospitals and doctor’s office will refuse to let you see your original chart. Recently, I was informed by the head of the medical records department of the Kingston Hospital that they do not permit original chart reviews! When you get stonewalled by the doctor or hospital, what do you do?

Step one is to ask to speak to the clerk’s supervisor in the medical records department. Go up the chain of command! If you get stonewalled by the head person of the medical records department, you need to assert your rights. Section 18 of New York’s Public Health Law gives you the unqualified right to review the original medical records. This is your right under New York law and you cannot be denied the right to review the original medical chart.

If the medical records custodian tells you to take the proverbial hike when asking for an original chart review, and you have gone as far up the chain of command at the hospital, now you need to contact the New York State Department of Health to inform them of the hospital/doctor’s violation of section 18 of the Public Health Law. THIS WILL GET THE DOCTOR’S ATTENTION!

To take it a step further, you should notify the hospital/doctor that their refusal to allow you to inspect your original medical records is a violation of state law (Public Health Law section 18) and federal law (HIPAA) and that you intend to enforce your rights through the Department of Health and the U.S. Department of Health and Human Services. Do you think you will get your original chart review now?

Why you should bring a color laser scanner to the original chart review

One practical tip: when I do an original chart review, I bring a laser color scanner to copy the original chart in color. With the medical records scanned in color into a pdf, I now have an electronic file that I can easily e-mail to medical experts easily and at no cost. A color copy of the medical records is always preferable to black and white, as some colors (such as red ink) have added meaning in a medical record.

Call me if you have questions or want more information

If you have any questions about original chart reviews or obtaining your medical records, I welcome your phone call on my toll-free cell at 866-889-6882. You can also request a free copy of my book, The Seven Deadly Mistakes of Malpractice Victims, if you want more information about the importance of medical records to your medical malpractice case.