SOAP-Symptoms, Objective signs, Assessment and Plan
Medical records are typically kept in a form described with this acronym.
In almost every injury case I handle, my client will claim some error or mistake in the medical records created of their treatment and care. A miscommunication or even the method of recording can produce mistakes in any one of these parts of the record.
A Few Examples:
In a medical malpractice case I am handling, a gynecologist noted that a rectal exam was performed during a gynecologic exam and was normal. In this case, whether the exam was in fact normal, or was done at all, was a significant fact. The client said that never, in her 10 years of being treated by this ob-gyn, had he ever done an exam of her rectum (which requires a finger be placed to check the walls of the rectum). When he was cross examined in deposition, he admitted that his electronic medical record system only required that he check a box for “normal gyn exam” and the wording for each part of the exam would automatically populate the record. In other words, even if he never in fact did a rectal exam, by simply checking the box “normal gyn”, the computer would automatically note “normal rectal exam.”
The cancer patient whose surveillance CT study, the Radiologist noted, showed changes and that Recurrent Cancer could not be definitively ruled out without further testing. The patient was told by the Treating Physician that the study was Negative for Recurrent Cancer. The patient did not learn about the Radiologist’s report until after he suffered physical symptoms, 8 months later, and the Recurrent Cancer cells had now definitely entered his bloodstream.
I have warned in past blogs that retrieving and reviewing your medical records is essential to preventing medical mistakes. Your physician should never be offended by such a request, in fact, should applaud such concern for your own medical care. Your access to your own medical records is governed by Federal Law. If you need to get to sleep fast, I welcome you to read 45 CFR 164.524. Let me summarize it for you here:
1. You have a right to access, inspect and obtain a copy of your medical records except in very few circumstances such as psychotherapy notes or records created solely for use in legal proceedings;
2. You don’t have to, but you should, put your request in writing;
3. The medical provider must provide a response within 30 days;
4. The medical provider must produce the record in the form and format you request if it is readily producible in such format. So, if you want paper copies or a copy of the electronic medical record in PDF format, if it can be produced in that way, it should be.
5. The medical provider may provide a summary of the information requested, but only if you agree to receive that instead of the whole record.
6. The medical provider is entitled to seek reasonable fees for the labor in copying the records, the supplies necessary to create what has been produced (paper or CD disc); postage, and for the preparation of a summary or explanation if you have requested this.
7. If you make a request of an entity that does not have your records, but the entity knows where the records are, the entity should tell you where the records are in fact maintained.
Now knowing that Federal Law requires a medical provider to give you medical records upon request, please act upon that right. I suggest that you send a letter to each of your medical providers, now, that essentially says as follows:
“Dear Dr., in an effort to be best informed regarding my own medical care, I would appreciate you providing me a copy of my medical records, including, but not limited to, your office notes, consultation reports, diagnostic study reports, lab reports and billing statements for treatment given to me from the date I first became your patient to the present. If there is a cost for providing these records, please advise me and I will be sure to pay it.”
Once you get your records, review them. Make sure your past medical history is properly noted. Make sure the doctor has properly indicated your allergies and what medications you are taking. If the plan the doctor has indicated in his notes is different than your understanding, make sure the inconsistency is rectified. Any changes that need be made to your medical records should be put in writing.
There is nothing more important than your health. Your physicians will appreciate your active involvement in your own care and the consideration of them as teammates in your goal to live a healthy life.
Tony Baratta is a trial attorney in Huntingdon Valley, PA who represents clients who have been seriously injured including due to medical mistakes. Tony is the founding partner of Baratta, Russell, & Baratta and on the board for the Philadelphia VIP. Tony is a Nationally Certified Civil Trial Advocate, AV Rated Preeminent by Martindale-Hubbel and a member of the Pennsylvania Brain Injury Association (BPIA). He is also a member of the Million Dollar Advocates Forum for trial attorneys and voted one of Philadelphia’s Super Lawyers 2008-2015.