Quick answer
Request the admission notes, clinical notes, nursing notes, consent forms, operation notes, medication charts, test results, scan reports, referral letters, discharge summary, billing records and follow-up records. The exact list depends on what happened, but a discharge note alone is rarely enough.
Key takeaways
- Request the admission notes, clinical notes, nursing notes, consent forms, operation notes, medication charts, test results, scan reports, referral letters, discharge summary, billing records and follow-up records. The exact list depends on what happened, but a discharge note alone is rarely enough.
- Write a records request that identifies the patient, hospital, treatment dates and departments involved. Ask for the records in writing and keep proof of the request. Do not mark or alter original documents. Keep a separate timeline and questions list.