What is Medical Record Pagination?

In a clinical negligence case (otherwise known as medical negligence), the main source of evidence is what is contained within the contemporaneous medical records. This is because medical records are written at the time or close to the time that an event occurred and therefore should give an accurate insight into what happened.

It is therefore very important, that when health professionals record what treatment and care was provided, they do so promptly and record accurately details 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 going forward. Records should be legible and should include details of who recorded the information as well as being dated and timed, although this is unfortunately not always the case.

From a legal perspective, when a solicitor takes instructions on their client’s case, they must then apply for ALL medical records relevant to the treatment they have received. Once obtained, these can then be sorted into a logical format and indexed into sections and page numbered accordingly. This enables those working on the case to navigate the records with ease. A chronology will focus on the salient information within the notes which will assist your medical expert in directing them to the relevant notes to enable them to prepare their report.

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

Having the medical records sorted in this way prior to commencing substantive investigations will also mean that any records which appear to be missing can be obtained and added to the bundle and all radiology may be checked off against what is indicated within the records and what is provided for on disc by the treating hospital or dental surgery.

When applying for General Practitioner records, it is not enough simply to obtain the computerised records. Full records are required even if they are not relevant. Your client may have an underlying condition dating back before systems went computerised and it is crucial for the solicitor and expert to have the full picture of the client’s past medical history and family and social history where relevant.

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

Hospital records should also be obtained in their entirety and where it relates to a birth injury, both mother and baby records should be requested. Further, where outpatient care has been arranged by a hospital, such as district nurse care or physiotherapy treatment, these records should also be obtained in order that both solicitor and expert have a full and detailed understanding of the follow up care arranged and or provided. Where a patient has died while in care, pathology reports and the post mortem report should be obtained. Where a complaint has been made, all complaints correspondence and reports should be obtained. Where protocols are referred to within the records, these should be obtained as these can be helpful in assessing the standard of care expected and whether treatment and care has fallen below those standards.

In preparing the case thoroughly at the outset and collating all the relevant records will ensure that those issues which your client has instructed you on can be explored from an early stage giving your client the best possible prospects of dealing with their case thoroughly.

Thorough preparation of medical records will not only help you, your expert, and barrister you instruct, and the court; it will help your client in ensuring that no stone is left unturned in the pursuit of establishing a successful case.