Here are forms, letters, and information to
help you collect and send information to Agencies. These forms are legal
documents that have places that you only have to add your personal information
in. And read the "Tips on Sending Forms & Letters"
Forms and letters are PDF files and require the program called "Acrobat
Reader" to fill them in and print the form out.
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Good Record
Keeping
Keeping good records are important. They should
be easy to refer to when doing a task and being asked a question, or researching
your next steps in a case.
1. Make several copies of original documents and
keep the receipts for the cost of copying.
2. Keep them in a labeled folder (example: Medical
Records, Court Records)
3. Keep a written record of all phone calls you
make and receive. Write the date & time, phone number, person you spoke
with, brief note of conversation. If the person was not there, write the
information you left with a person or on an answering machine.
4. Keep phone bills for the calls you are charged
for in you case. Good for when they said you never called them. You have
this bill with their number, date, time, and minutes for proof.
5. Keep receipts for stamps, other postal costs,
and costs of obtaining copies of your records that refer to you case.
6. When submitting for records, have documents
Notarized, and if mailing, send them CERTIFIED MAIL RETURN RECEIPT REQUESTED!
How to
get Medical Records
.gif) MEDICAL RECORDS
Obtain ALL of the
nursing home, clinic, urgent care, emergency room, ambulance, visiting
nurse, occupational therapy, speech therapy, physical therapy and respiratory
therapy records and ALL doctor and hospital records.
Information is often
obtained from seemingly obscure records, hence the need for ALL of the
medical records.
Sometimes urgent care,
ambulatory care clinics, emergency rooms, ambulances, nursing and various
therapy services, etc., are independent contractors. Establish with the
hospital or institution what care is provided by independent contractors
to ensure you are ordering ALL of the available medical records.
Even if all of the
available medical records are not part of the alleged incident and hence
are not subject to the medical review, they should still be obtained as
reference material. The records just prior to and after an alleged incident
are especially important in providing documentation as to the person’s
medical condition, the extent of the alleged injuries as well as an indication
of any probable long-lasting complications that may now exist.
HOSPITAL RECORDS
Hospital records include,
but are not limited to: Admission Information/Summary, Discharge Summary,
Admission History and Physical, Doctor's Progress Notes, Emergency Room
Records, Consultation Reports, Doctor's Orders, Operating Room Report (Physician
and Nursing), Laboratory Reports, Graph Sheets, Treatment Sheets, Medication
Sheets, Anesthesia Record, X-ray Reports and Radiologist Reports, Physical
Therapy Records, Speech Therapy Records, Occupational Therapy Records,
Nurse’s Notes, Nursing Care Plans and Nursing Progress Notes.
Often Treatment and
Medication Records are double-sided with initials on the front side and
the signatures on the reverse side. Be sure to obtain the signature portion
of any initialed document. This will allow identification of a particular
individual should the need arise.
DON'T FORGET ABOUT THESE MEDICAL RECORDS
In non-hospital settings,
some terms for the documents used will be the same and some will not be.
Look for these items in addition to the ones listed under hospital records:
KARDEX files, MAR or MARS sheets, Nurse’s Aids or Nursing Assistants Notes
and Treatment Records, Nursing Treatment Records, Physical Therapy, Speech
Therapy, Occupational Therapy, Rehabilitation Therapy or any other form
of therapy records, Visiting or Home Care Nursing Records, records from
Independent Medical Laboratories and Ambulance Records (EMS --- Emergency
Medical Service), Emergency Room Records (these are often not part of the
hospital records where the emergency room is operated by an independent
contractor).
In some situations,
emergency responding personnel such as the local police and rescue portions
of the fire department will also apply and will be separate from other
EMS personnel in the storing of their records. If a facility is state licensed,
obtain a copy of the state’s investigation and licensing inspections for
the year (s) being investigated. [Generally, this is a matter of public
record obtained from the designated state regulatory agency.]
For an Expert Report,
it is ABSOLUTELY CRITICAL to have ALL available medical records.
*The information contained on these pages are for informational
purposes only. The pages were created per requests received by our visitors.
Remember, when needing legal advice, please consult an Attorney. We are
not responsible for any typos, nor for the outcome of usage.
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