A Medical Record Retrieval Checklist for Personal Injury Cases

Personal Injury cases revolve around the medical records of the patient. Retrieving a full and complete copy of a client’s medical records is a burdensome and lengthy process. Overlooking a step may lead to starting the retrieval procedure from the beginning. A sophisticated and prudent way of handling this is to run through a checklist. In this article we will take you through a medical records retrieval checklist for personal injury cases that can help you assemble all of the records necessary to pursue a claim or civil action.

 Authorization for disclosure of protected health information:

Retrieving medical records must first start with obtaining a HIPAA compliant form signed by the patient. Without a HIPAA compliant authorization, the providers will not release the records. Before retrieving the records attorneys need to understand which records or portions of records will have the information that is vital to proving the case. In turn, the attorney must ensure that all of the relevant records are retrieved.

Medical Records Retrieval Checklist for Filing Personal Injury Cases

Below is a Medical Record Retrieval checklist of records that should be retrieved in every case.

  • Records of diagnosis and prognosis of the Injury – Include the provider’s notes on the condition of the patient and the outcome of the treatment post-injury. This will give a complete understanding on why a certain treatment was performed and the importance of choosing that treatment instead of an alternative course of treatment.
  • Records of Emergency Room visit (if any) – There is a separate record created if the patient is treated in an emergency room. It is important to obtain this record as it is entirely different from the regular hospital records.
  • Initial medical procedures notes – These records offer clarity on the connection between each service offered or procedures performed by the provider. It also includes fine points on how the services were performed.
  • Provider’s findings for the cause of injury– Notes of a provider may identify and set forth the direct cause of injury or condition.
  • Preexisting conditions and medical records related to them – Pre-existing conditions and symptoms of them worsening post-injury is typically noted by the provider.
  • Provider’s prescription- Medications which are given to the patient due to the injury are documented.
  • Follow-up treatment plan– Documents containing details of post-discharge follow-up with the doctor or another provider.

Other important documents include itemized bills and ledgers for all the treatment given, testing reports, MRI scans,  and x-rays.

Retrieving and obtaining a full and complete copy of all medical records related to an injury is vital, as a missed or overlooked record may have information that strongly or conclusively supports your client’s claim or case.  In addition, once an attorney finds that not all of the records were obtained, the retrieval process must be started from the beginning. Therefore, before retrieving the records it is important to strategize about what records are needed to ensure that during the retrieval all of the documents are obtained.


AcroDocz assists law firms and attorneys in retrieving all necessary medical records promptly. To learn more about our medical records retrieval services, please fill the form below and we will get in touch with you.


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