The medical records guide

You have the right to the records

Under federal law, patients, and parents on behalf of their minor children, generally have the right to obtain copies of their medical records from hospitals and clinicians, usually for a reasonable copying fee and within a set period. Hospitals have a records or health information department that handles requests; many now provide records through an online portal. The exact procedure and any state-specific rules are matters for attorney review and are not stated here.

Which records matter

Ask for the complete record, not the summary. The sets that matter most in a birth injury review are:

• Prenatal records from the obstetrician or midwife: visits, ultrasounds, estimated fetal size, test results, any noted risk factors.
• Labor and delivery records: the admission note, nursing notes, the complete fetal heart rate monitoring strip (ask for it specifically; it is often stored separately), medication records, progress notes, the delivery note and any operative report.
• Newborn records: resuscitation notes, Apgar scores, cord blood gas results if taken, NICU notes, imaging and any cooling therapy records.
• Placenta pathology, if the placenta was examined.
• Follow-up records: pediatric, neurology, therapy and developmental assessments.

How to ask

1. Write to the hospital’s health information or medical records department. Ask for “the complete medical record” for the mother’s admission and for the baby, and name the monitoring strip and placenta pathology explicitly.
2. Keep a copy of the request and note the date. Ask when to expect the records.
3. If something seems missing when the records arrive, ask again in writing and name what is missing.
4. Keep everything together, in date order, and do not write on the originals.

Writing down what you remember

Memory fades. Soon, and for your own use, write down what you remember of the labor and birth: who was present, when things changed, what you were told and when. Date it and keep it with the records. Keep it factual; it is a record of your experience, not an argument.

What the records cannot tell you by themselves

Reading your own records can be distressing, and it is tempting to look for the moment things went wrong. The records are interpreted by clinicians and, if you choose, by the experts an attorney engages; a note that looks alarming to a parent may be routine, and a routine-looking note may matter. Clinical bodies call for a broad evaluation of everything that may have contributed to a newborn’s condition, which is exactly what careful reviewers do with these records.