When medical care leaves you with an unexpected injury, you may wonder what happened and whether someone could have prevented it. You may remember what your doctor told you, but proving what happened often requires more than your recollection. Your medical records can document the care you received and help an attorney assess whether a mistake contributed to your injury.
Here are the records that can provide important information about your care.
Medical history and examination notes
Your medical documents can show what your provider knew about your condition and how they evaluated you. These records may include:
- Symptoms and complaints you reported
- Relevant medical history
- Physical examination findings
- Diagnoses and treatment decisions
- Changes in your condition
These can also help show whether your provider recognized important symptoms and responded appropriately based on your condition.
Diagnostic tests and imaging results
Test and imaging records can show whether your provider recognized and responded to important findings. These may include:
- Blood and laboratory test results
- X-rays, CT scans and MRIs
- Pathology or biopsy results
- Diagnostic reports and interpretations
- Follow-up testing
For example, an abnormal result followed by no appropriate follow-up could raise questions about whether your condition received timely attention.
Treatment and medication records
Your treatment plan can contain crucial information about the care you received and changes made after. Look for:
- Medications and dosages
- Medication changes
- Procedures performed
- Operative or procedure reports
- Your response to treatment
If you later received a second opinion, comparing the records from both providers could show how their approaches differed. This may be especially useful if the alternative plan produced a better result or addressed an issue that the original care did not.
Hospital and discharge records
Hospital and discharge records can show what happened during your stay and what instructions you received afterward. These records may include:
- Nursing notes
- Admission and discharge information
- Follow-up recommendations
- Referrals
New York law also gives patients a right to access their health records. Under Public Health Law Section 18, you can make a written request to inspect your records and request copies, subject to certain exceptions.
Gather the records that matter
Your records can provide important evidence about the care you received, but they do not automatically establish malpractice.
A medical malpractice action generally must begin within two years and six months of the alleged act, omission or failure, so seeking legal guidance as soon as possible is important. If you believe a medical error caused your injury, gathering the relevant records and having an attorney review them can help you understand whether the care you received supports a potential claim.