Remember These Points If Asked for Your Records

By Johnson, Lee J. | Medical Economics, June 25, 2011 | Go to article overview

Remember These Points If Asked for Your Records


Johnson, Lee J., Medical Economics


What do you do if you realize that your records actually may do harm to a patient's lawsuit? The answer is, not much.

Instances in which your records may damage a patient's lawsuit case could occur in various circumstances. Maybe your patient is suing other doctors for malpractice and your records reflect that you did not concur with the prior treating physician's diagnosis or course of treatment. Or maybe in a personal injury lawsuit, your records show that the patient was not really injured and, therefore, the damages were small. Yet another possibility is that you were a prior treating physician and your records indicate the diagnosis and treatment of a pre-existing condition. Maybe those are exactly the damages that are being claimed in the lawsuit. The records then would show that all or some of the damages claimed were not the result of the current tort and would limit the amount of any recovery for the patient.

In a recent unreported case, a patient's car was rear-ended in a motor vehicle accident, and the patient sued the other driver, claiming damages of whiplash, headaches, back and neck pain, emotional pain, and other psycho-neurologic disorders. The doctor's records went back many years. They reflected that the patient complained of headache and neck and back pain and was treated with pain medication and referrals to an orthopedist and a psychiatrist- and that the patient had been seeing a chiropractor for years.

This information would limit the potential recovery in the case. The plaintiff must prove proximate causation, and it raises the issue: 'Were the damages caused by the accident, or would they have happened anyway?" A pre-existing condition weakens the plaintiff's causation argument. Yes, there are damages, but the damages may not have been caused by the accident.

What follows is a series of questions asked by the doctor in the aforementioned case. You might ask these questions as well if a patient/plaintiff's lawyer or defense attorney requests your records.

* Can I ignore the request or refuse to send the records?

Make sure the patient has signed a Health Insurance Portability and Accountability Act- compliant authorization form. The patient must waive the doctor-patient privilege for you to have the legal right to send the records. If a valid authorization exists, then you may as well comply.

If you do not send the records, then the lawyers indubitably will ask the judge to order the release of the records during the process of discovery. Courts routinely grant such motions because they want all the evidence to be available. Not responding to a court order would put you in contempt of court. So you may as well release the records when the attorney requests them.

If the patient or the patient's family is equivocal and tries to rescind the authorization, or if they threaten you with lawsuits or bodily harm, however, then it may be safer for you to wait for the judge to order the release. The judge has judicial immunity, and his or her order will have the force of law. A court order, in other words, can buy a little immunity for a doctor in touchy circumstances.

* Can I tell the lawyers I don't have records?

In every state, the law and professional medical conduct standards require you to keep a record justifying your diagnosis and course of treatment. If you claim not to have records, then you could be subject to sanctions.

* Can I destroy the records?

If you destroy records, then you could be charged with spoliation of evidence, which is a criminal act.

Destroying records will not help your patient's case, because any jury will infer that the records contained damaging information.

Same result if you destroy a few of the pages, such as information referring to referrals or a diagnosis of psychosomatic pain. Missing pages will be a red flag to a jury that those pages contained something extremely damaging.

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