What Records Are Needed in Medical Malpractice Cases?

A medical malpractice case is one of the most stressful lawsuits a person can go through.  These cases are usually brought on because a trusted medical professional made a mistake that affected someone’s life.  The victim can feel helpless and as though the control they thought they had over their life was taken away.  Instead of letting this haunt them, many take it to the courts to get their closure.

Medical malpractice cases are complicated by nature, though.

Here are the records you need for these cases and how you can help your medical malpractice lawyer ensure that you get every cent you deserve.

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Admitting History and Physical

Your history at this hospital, and any hospital, is crucial because it shows the record of what you’ve experienced.  This paperwork may also include your informed consent for any operations. Although it does mean you signed that you understood the risk of a process: don’t forgive the doctors for any grievous mistakes.

Operative Reports

This report, dictated right after a procedure is completed, is often the smoking gun.  It should say how the process went and if there were any complications in your doctor’s words.  Unfortunately, many doctors don’t notice what they’ve done wrong at this point and will falsely call the operation a success even if you suffer after.

Progress Notes

These are notes taken during the surgery, usually by dictation, to update how the procedure is going.  These are more common for longer surgeries and should be poured over carefully in any malpractice case.

Physician Orders

These orders are a permission from your doctor for you to have any needed laboratory testing done.  This paperwork could be useful if these orders allowed the lab to find a mistake the physician made.

Nurses’ Notes

As another pair of eyes on what you experienced, nurses’ notes are a subjective view of what happened.  Although they obviously can’t see everything, they can list out what they do see.  These notes may also include the nurse’s notes that looked you over after you reported you were having difficulties after a surgery or treatment.


If you had to go to another doctor besides your usual one, you might need your paperwork for the consultation.  This could mean a physical therapist, a chiropractor, or one of many other medical professionals, depending on your case.


Your anesthesia paperwork will detail what type of anesthesia you received, who gave you the dosage, and when you received it.  This information may be vital if you find you’ve had a reaction to it or if it didn’t work as prescribed.


Paperwork detailing what medications you take, and have taken, is vital for countless reasons.  Not only does it show how much you’ve had to spend to recover, but it also will show the extent of your injuries and time spent on recovering.  


This paperwork goes over what information is needed from the radiology department.  Not every procedure requires paperwork from this department, but they’re a vital part of any hospital.


Anything you were tested for, any scans, and any other information you have will end up in your laboratory paperwork.  This paper trail is critical to have because it gives a lot of evidence on what you’ve been through.

FG Editorial Team
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