If a hospital loses or alters your medical records, you should ideally have a medical malpractice lawyer in Harrisburg review them for intentional or accidental alterations and send preservation letters to prevent any further changes. Those official records document your treatment, your condition, and the decisions made about your care. Missing or revised entries can significantly affect your ability to prove what happened to you and who you can hold responsible for your losses.
If you’ve yet to contact Marzella & Associates to explore your next steps with our Harrisburg medical malpractice attorneys after learning a hospital lost or altered your records, here’s what you can do to protect and strengthen your claim.
Request Your Complete Medical Record Immediately
The HIPAA Privacy Rule requires healthcare providers to provide copies of your medical records upon request. Submit a written request to the hospital for your physician and nursing notes, medication administration records, lab reports, electronic audit trails, and incident reports. Under HIPAA, providers must generally respond within 30 days. You may be charged copying fees, but you’re not required to explain why you’re requesting your records.
Preserve Evidence of Any Suspected Changes to Your Record
If you suspect record tampering, refrain from confronting the hospital staff. A Harrisburg medical malpractice lawyer can issue a preservation letter to prohibit further modifications to your medical records or destruction of evidence.
Hospitals are required to maintain complete and properly documented patient records. Pennsylvania courts recognize the doctrine of spoliation, meaning that when evidence is destroyed or altered, a judge may allow the jury to assume the missing records would’ve supported the patient’s claim rather than the hospital’s defense. See Schroeder v. Commonwealth, 710 A.2d 23 (Pa. 1998). So, when your records go missing or are inconsistent, that fact can itself support a negligence claim.
However, take note that healthcare providers can make late entries or corrections if they’re clearly labeled, dated, and signed, and if the original entry remains visible. What raises concern is backdating, deleting prior notes, or editing an entry without identifying it as a correction.
Obtain Records from Relevant Outside Providers
If your hospital records are incomplete or missing, gather documentation from:
- Ambulance services
- Primary care doctors
- Third-party medical specialists
- Pharmacies
- Insurance billing statements
An emergency transport record may confirm vital signs or medication administration that wasn’t recorded in the hospital chart. Similarly, pharmacy dispensing logs may verify prescribed dosages. Cross-referencing these outside records can reveal inconsistencies and negligent care.
Document Your Own Timeline
If applicable, write down everything you remember about the hospitalization, including conversations with doctors, medication changes, times of procedures, and statements made by the staff. Ask family members or friends who were present to provide written accounts. Proper documentation strengthens your claim’s credibility if records are disputed.
If you suspect any issues with your medical records, act quickly. Request your full chart in writing, download your patient portal information, preserve your discharge instructions and prescription labels, keep all your medication bottles, and avoid writing on original documents.
Find Out How Our Medical Malpractice Attorneys in Harrisburg Can Serve You
If you need help tracking down lost medical records or verifying whether they’ve been altered, call Marzella & Associates at 717-876-8681 or contact us online for your no-fee case review. Our medical malpractice lawyers in Harrisburg can find out what happened to your records, recover any backup documentation, and safeguard your malpractice claim and right to compensation.