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How to Gather Evidence for Your Medical Malpractice Claim

April 20, 2022

If you have been the victim of negligent care rendered by a medical professional, you may be entitled to pursue a medical malpractice claim. A successful claim will require extensive evidence to prove how your provider’s care was negligent and how it caused you to suffer injury or harm. Below is some important information about gathering evidence for medical malpractice claims. 

Types of Medical Records to Gather

Examples of medical records you should gather for your medical malpractice claim include:

  • Medical test results
  • Lab testing results
  • Radiology films and imaging
  • Operative reports
  • Consultation reports
  • Prescription orders
  • Medication records
  • Doctor’s notes
  • Nursing progress notes

Under the Health Insurance Portability and Accountability Act (HIPAA), you have the legal right to request all documents contained within your medical record. A medical provider cannot deny you access to your record or charge you fees to access your records, although a medical provider can charge a processing fee for producing and mailing a copy of your records. If a patient cannot request a copy of their medical records themselves, a copy may be requested by certain authorized individuals, including:

  • The parent or guardian of a patient who is a minor
  • The executor of the estate of a deceased patient
  • An individual appointed by the patient under a healthcare power of attorney
  • Any other party authorized to access the records under a release executed by the patient 

How to Obtain Your Medical Records

Normally, you can obtain a copy of your medical records from a provider of your by sending a written request. Many medical providers also have forms (often online) that patients can fill out to request a copy of their medical records. If a provider does not have a form, you can send your provider a letter to request a copy of your records. The letter should include, at a minimum:

  • Your full legal name, date of birth, and Social Security Number/Tax Identification Number
  • Your address, phone number, and email address
  • The records you wish to access and obtain a copy of 
  • Your signature

Before sending a written request for your records, you may want to contact your provider to confirm where you need to send your request, as your provider may have a separate records department that handles requests for access to records.

Other Evidence You Need for a Medical Malpractice Claim

While medical records often serve as one of the key pieces of evidence in a medical malpractice claim, these cases also involve other kinds of evidence, such as:

  • Staffing records from the facility where you were treated
  • Surveillance footage
  • Witness testimony

If you can, you should take the time to write down the names of any persons who treated you or that you interacted with during the alleged negligent treatment, including doctors, nurses, orderlies, or any other hospital staff.

Finally, a medical malpractice claim will typically also require you to obtain opinion testimony from an expert witness, usually another health professional of the same specialty as the provider you are filing suit against. This expert testimony is needed to establish what the standard of care was in your case and how your provider’s treatment and conduct failed to comply with the standard of care and caused your injuries. 

Contact A Medical Malpractice Attorney for a Consultation About Your Hospital Error Case in Pennsylvania

Were you or a loved one injured due to medical malpractice in Pennsylvania? Then you need to talk to an experienced medical malpractice lawyer as soon as possible for guidance on how to proceed. The Pittsburgh medical malpractice attorneys at Berger Lagnese & Paul, LLC are prepared to assist you with your legal claim. We represent victims of negligent surgeons, doctors, nurses, and pharmacists throughout Pennsylvania, including Butler, Cranberry Township, Erie, and Greensburg. Call us today at (412) 471-4300 or fill out our online contact form to schedule a consultation. Our main office is located at 310 Grant St., #720, Pittsburgh, PA 15219.

The articles on this blog are for informative purposes only and are no substitute for legal advice or an attorney-client relationship. If you are seeking legal advice, please contact our law firm directly.

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