If you are trying to understand what happened during your care in Atlanta, your medical records are the most important evidence you can gather. Our Atlanta medical malpractice lawyer can request records from every provider involved and review them with a qualified physician. Moriarty Medical Malpractice Lawyers prepared this guide to explain your right to your records, how to request them, and what to gather.
Your Right to Your Medical Records
Federal law gives you the right to see and receive a copy of your health information from doctors, hospitals, and health plans. According to HHS guidance on the HIPAA Privacy Rule, the right applies to the records a provider uses to make decisions about you. Providers must give you the records in the form and format you request if they can readily produce them that way. They may charge only a reasonable, cost-based fee. The right has limited exceptions, so a provider may be able to withhold a small category of information in specific situations.
You can also direct a provider to send your records to someone else, such as a new physician or your attorney.
Georgia law adds its own protections. Physicians and other providers must furnish a copy of the record within 30 days of a signed written request and must keep records for at least 10 years from the patient’s last visit, according to the Georgia Attorney General’s Consumer Protection Division.
How Long Providers Have to Respond
Under the HIPAA Privacy Rule, a provider must act on a request no later than 30 calendar days after receiving it. If it cannot, it may take up to 30 more days, but only if it gives you a written explanation of the delay and a completion date within the first 30 days, according to the HHS Office for Civil Rights.
Records available through an online patient portal may be accessible sooner. Complete hospital charts, imaging, and records held by outside labs or billing companies can take longer to assemble.
How to Request Your Records
- Put the request in writing and sign it. Many providers have their own request form, but a signed letter also works.
- Identify yourself. Include your full name, date of birth, and contact information.
- Be specific. Name the facility or practice, the dates of treatment, and the types of records you need.
- Ask for the complete record. A visit summary or discharge paper is not the full chart.
- State your preferred format. Ask for electronic copies, paper copies, or a portal download.
- Keep a copy and follow up. Note the date you sent the request, and call after several business days to confirm it was received.
What to Gather
- Office and hospital charts, including physician orders, progress notes, and nursing notes
- Emergency department records, which can matter in emergency room malpractice claims
- Imaging studies and radiology reports, which are often central in failure to diagnose cases
- Lab and pathology results
- Surgical, anesthesia, and recovery room records
- Medication lists and pharmacy records, including dispensing records in a medication error case
- Labor and delivery records and fetal monitoring strips for birth injury claims
- Billing statements and insurance explanations of benefits, which help document damages
- Patient portal messages and telehealth visit records
Hospital records can involve several departments. Nursing flowsheets, medication administration records, and the time stamps in the electronic chart often show exactly when events occurred, which is why they matter in hospital negligence cases.
What Records Cost
When you request your own records, the federal cost-based fee rules apply. Georgia’s separate fee schedule for records requested by attorneys and other third parties does not apply to your own request, according to the Department of Community Health.
If a Provider Refuses or Delays
If a provider does not respond or refuses without a valid reason, follow up in writing. You can also file a complaint with the HHS Office for Civil Rights. A complaint may prompt a response, but it does not resolve a malpractice claim.
How Records Are Used in a Malpractice Claim
Records are the foundation of every element of a claim. They show who treated the patient, what the providers knew and when, what was done, and how the patient’s condition changed. A qualified physician compares those records with accepted practice before a lawsuit can be filed. Our guide to proving a malpractice claim explains how the records support each element.
A records request can also affect the filing deadline. Georgia allows a properly made request to pause the deadline in limited circumstances, but the requirements are strict. Our guide to Georgia filing deadlines explains how that rule works. For other first steps, see our guide to the first steps after malpractice.
Talk With Our Attorneys
Moriarty Medical Malpractice Lawyers represents patients and families in Atlanta and nearby communities, including Stonecrest. Contact us to schedule a free consultation. Our attorneys can request the records for you.
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