What Medical Records Do You Need to Prove a Malpractice Claim?

Seeking medical treatment for an illness or injury requires a leap of faith that the doctor and other providers responsible for your care meet the best possible standard of care, or at least the standard accepted by the medical community, which is their legal obligation.

Unfortunately, medical providers sometimes violate their duty of care by failing to order the appropriate tests, failing to accurately interpret test results, or neglecting to obtain a complete patient history. In other cases, a doctor’s error during a surgical procedure can cause serious permanent harm. In the event you were injured due to a medical malpractice incident, contact our medical malpractice lawyer in Chicago for legal assistance.

These are examples of actionable medical malpractice, but what medical records and other evidence does a medical malpractice victim need to prove their claim?

Proving a Breach of the Standard Of Care Occurred

Physicians and all medical providers in Illinois are held to a higher standard of care than the general duty of reasonable care owed by all persons to one another. When performing their duties to care for a patient, they must provide at least the level of care accepted as standard by the medical community. To gain a settlement or win a court award for damages caused by medical malpractice, the injured patient or their surviving family members must provide substantial evidence, including the following medical records:

• The patient’s complete medical history
• A copy of the results of their most recent complete physical before the malpractice occurred
• All of the patient’s medical records from the facility where the malpractice occurred
• Copies of all lab results, diagnostic testing results, and medical imaging tests from before and after the malpractice occurred
• All treatment records, including medication orders and anesthesia records
• Physician’s notes, consultation reports, and nurses’ charts from the patient’s stay at the hospital or medical facility
• Administrative records showing the transfer of patient history between medical facilities and providers
• Hospital admission and discharge records

Under Illinois law, 210 ILCS 85/6.17, medical facilities must maintain meticulously detailed patient records and retain them for at least 10 years. Hospitals and other medical facilities have a legal obligation to produce all requested documents and records in connection with a medical malpractice claim.

The Importance of a Medical Report After the Malpractice 

In addition to the complete treatment records from the facility where the malpractice occurred, it’s crucial to obtain a medical report from a comprehensive assessment performed by a trusted provider who is unaffiliated with that facility. This record highlights the harm caused by the malpractice by showing adverse changes in the patient’s medical condition since the malpractice occurred.

Additional Evidence In a Medical Malpractice Case

Medical records from before, during, and after the malpractice are a key aspect of proving that malpractice occurred, but additional evidence is also required. Evidence in medical malpractice claims also includes the following:

• Medical bills, invoices, and receipts proving that the patient suffered economic damages from the malpractice
• Employer’s statements showing lost earnings
• Medical expert testimony
• Eyewitness testimony

The evidence in a medical malpractice case must show that a doctor/patient relationship was in place at the time the malpractice occurred, that the medical provider owed a duty of care to the patient to treat them at the medical community’s accepted standard of care, that the medical provider breached this duty, and the patient suffered damages from the breach of duty.

How Can a Medical Malpractice Attorney Help?

Medical malpractice is a uniquely complex category of personal injury law, requiring specialized knowledge and access to medical experts. Contact Smith LaCien to represent your best interests throughout the process to assertively advocate for your right to compensation for your losses.