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After a serious medical injury or unexpected death, request the patient’s records promptly. The patient can request their own records. After a death, the person authorized under state law to act for the deceased patient or their estate may request them. If the patient is deceased, ask the hospital what documentation is required to establish that authority. Hospitals deal with this issue often.

Make a Detailed Written Request

Send a written request to the hospital’s Health Information Management or Medical Records Department. Keep a copy and proof that the request was received. Certified mail is a good option.

Request records for the entire hospitalization, including relevant records immediately before and after the event you are investigating. List the following, where applicable:

  • Emergency department records and triage notes
  • Admission history and physical examination
  • Physician, nursing, and specialist notes
  • Orders, including changed and discontinued orders
  • Medication administration records
  • Laboratory results and pathology reports
  • Imaging reports and the actual images
  • Operative and anesthesia records
  • Vital signs, nursing flowsheets, and intake and output records
  • Fall-risk, skin, neurological, and other assessments
  • Consent forms and advance directives
  • Consultation notes and documented communications among clinicians
  • Rapid-response and resuscitation records
  • Transfer and discharge-planning records
  • Discharge instructions and medication reconciliation
  • Billing and itemized charge records

Ask for an electronic copy in your preferred format if the hospital can readily produce it. Request imaging files separately in DICOM format, along with the written reports. A portal view or a collection of reports may not include everything on your list.

Check for Records Kept Elsewhere

Some information may be stored outside the ordinary hospital chart. Depending on the care provided, ask about:

  • Ambulance and emergency medical service records
  • Pharmacy records
  • Blood-bank and transfusion records
  • Fetal monitoring strips
  • Cardiac rhythm strips and telemetry data
  • Ventilator and other medical-device data
  • Clinical photographs and wound images
  • Patient portal and telephone messages
  • Records the hospital received from outside providers
You may also need to send separate requests to an ambulance company, physicians’ group, imaging provider, rehabilitation facility, or another organization involved in the patient’s care.

Other Evidence May Require Legal Assistance

A standard medical-record request will not produce the hospital’s electronic audit trails, incident reports, risk-management and peer-review files, security-camera recordings, or raw device logs. These materials are outside the ordinary records release; some are legally protected. Obtaining any of these materials may require an attorney and depends on what the hospital retained and the applicable law.

If serious harm or death is involved, consider speaking with an attorney promptly about whether additional evidence should be requested or preserved. A preservation letter can identify materials that might otherwise be deleted under routine retention practices. Patients should not assume that listing these items on a standard form will produce them.

How Long Can the Hospital Take?

Under HIPAA, a hospital generally must act on an access request within 30 calendar days of receiving it. It may take one extension of up to 30 additional days if it provides a written explanation and a completion date within the original period. Some state laws provide a shorter deadline. Some hospitals produce medical records in 7 to10 days, though they are not required to do so.

Check What You Receive

Compare the records with your written request. If an item is missing, ask the records department about it in writing. Keep your request, proof of delivery, the hospital’s response, and an unchanged copy of the records you received.

Obtaining the complete record may take follow-up requests and separate requests to other organizations involved in the patient’s care.