Medical Records Retrieval

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LNCtips.com: Medical Records Retrieval


As a new legal nurse consultant, you probably don't think about the retrieval process for medical records.  If you're an expert or an independent LNC, the records show up on your doorstep.  But those records don't appear by magic.  A process occurs between the time the law firm identifies the needed records and the time you get them.

Either the law firm handles medical record requests in-house, or it outsources the process to a record retrieval service.  Let's look at the in-house process. 

The attorney or the person responsible for record retrieval starts the process by identifying which records to obtain.  The responsible person varies by firm.  It can be a subpoena clerk, a secretary, a medical records clerk, a paralegal, or a legal nurse consultant.  Let's say that you're the person who's responsible for obtaining medical records. 

Your next step is to determine the appropriate provider address.  While this sounds simple, it often isn't.  For example, national pharmacy chains, such as Walgreens, require law firms to submit record requests to their corporate legal departments.  Physicians sometimes keep their records off-site.  Regional health systems frequently have an address for record requests that is different from the address of their hospitals or clinics.  To obtain the correct address, you'll conduct an internet search to determine the provider's legal corporate information or you'll call the provider for the correct address.

Your next step is to draft the record request in the form of a HIPAA compliant authorization, such as this one from HealthPort, or medical records subpoena, depending on whether you work for the plaintiff or the defendant.  You'll then give the authorization or subpoena to the attorney for review.

The next step is to obtain the signature on the authorization or subpoena.  Patients sign authorizations and defense attorneys sign subpoenas.  Plaintiff attorneys often have their clients sign a number of blank authorizations when the case starts.  If you're working for the plaintiff, your next step is mailing the authorization to the correct provider address.

The process is more complicated for subpoenas than it is for authorizations.  You'll mail the subpoena to the plaintiff's attorney with either a certified letter (in some states) or a Notice of Production from Nonparty (in other states).  The letter/notice  explains that the subpoena will require the provider to produce medical records about the plaintiff.  The plaintiff then has a fixed period (usually 10-15 days, depending on state statutes) to object to the subpoena.  If the plaintiff has no objections, you will then file a Certificate of Non-Objection with the court.  You'll post the subpoena by certified mail or give the subpoena to an outside firm, called a process server, to deliver the subpoena to the healthcare provider.

After the delivery of the authorization or subpoena, the healthcare provider has a fixed number of days to comply with the subpoena (usually 10-15 days, depending on state statutes.)  You'll have to call the provider if it doesn't comply within the specified timeframe.  Physician offices aren't as well versed in record retrieval as corporate entities.  You may need to make several phone calls to remind physician offices to release the records.

Once you receive the records, you'll log them in, organize them, tab them, and maybe have them scanned.  You'll then copy and send them to others who will find the records on their doorsteps

Want to learn more about LNC skills for legal nurse consultants?  Check out the Archives.

...Katy Jones