Tips for preparing medical files for solicitors and medical experts

In a medical neglect case (also known as clinical negligence), the main source of evidence is what is contained inside the contemporaneous clinical files. This is because medical files are created at the time or near to the time that an event occurred and therefore should give a precise understanding of what took place.

Therefore, it is essential, that when health professionals document what treatment and care was provided, they do so quickly and file accurately specifics of their assessment, what treatment was given, what investigations were carried out, what was discussed with the patient and what the plan of care was in moving forward. Records should be legible and should contain details of who recorded the information as well as being dated and timed, although this is regrettably not always true.

From a legal viewpoint, whenever a lawyer takes instructions on their client’s case, they have to then request ALL medical records related to the treatments they received. Once received, these can then be sorted into a logical format and indexed into sections and page numbered accordingly. This lets those working on the case to get around the records easily. A chronology will focus on the salient details within the records which will assist your specialist in leading them to the relevant notes to enable them to put together their report.

Whenever indexing the medical records, it is important to put the details which will essentially include the main substance of your client’s treatment & care towards the top of the bundle (clinical records, nursing evaluation notes and medical correspondence). This ensures that when planning a chronology, the information can be pulled out of the medical bundle at an early stage and all other elements of treatment and care then be added and padded around the case, such as microbiology or radiology results or information on issues of consent to surgical procedures.

Having the clinical records sorted in this way before starting substantive investigations will mean that any records which appear to be missing can be obtained and put into the bundle and all radiology can be checked off against what’s indicated within the records and what’s provided for on disc by the treating clinic or dentist surgery.

When applying for Doctor files, it is not enough simply to obtain the computerised records. Complete records are required even if they’re not appropriate. Your client may have an underlying condition going back before systems went computerised and it is crucial for the expert and lawyer to have the full picture of the client’s past history and family and social history where appropriate.

When applying for Dentist records, similarly, both computerised and written records must be provided and radiology should always be requested for the sake of completeness.

Hospital records should also be acquired in their entirety where it concerns a birth injury, both baby & mother documents should be asked for. Further, where outpatient care is arranged by a hospital, such as physiotherapy treatment or district nurse care, these records should also be provided to ensure that both solicitor and medical expert have a full & detailed understanding of the followup care organised and or provided. Where a patient has died while in care, pathology reports and the post mortem report should be acquired. Where a complaint has been made, all complaints reports and correspondence should be provided. Where protocols are referred to inside the records, these should be obtained as these can help in evaluating the level of care expected and if treatment and care has fallen below those standards.

In considering the case thoroughly at the outset and collating all the relevant records will make sure that those issues which your client has instructed you on can be explored from an early step giving your client the best possible prospects of managing their case thoroughly.

Thorough preparation of clinical records will not only help you, your medical expert, and barrister you instruct, as well as the court; it will help your client in making sure no stone is left unturned in the quest for starting a successful case.