Here is a two prong approach to attempt to obtain two different sets of records, and then to compare them to see if there are significant omissions or variations between sets. This is costly, but in an important case, worth the effort.
First, the patient, or in the case of a minor, the parent, should personally request a complete copy of the medical records from Kaiser. Pursuant to HSC §123100, Kaiser must provide a complete set within 15 working days, but they can charge the patient/parent 25 cents/page.
Prepare a (HIPAA compliant) typed medical record request on plain paper, not listing any law firm or medical record service, just the name, address, and telephone number of the patient/parent, as the requesting party.
Importantly, list with great specificity all of the records requested. For birth injury cases you must separately request the records for the mother and the new born infant on separate forms.
Request all records from all facilities and in all forms, including paper and print outs of electronically generated records such as lab reports, or email communications.
Specify pre-natal records, labor and delivery records, and both inpatient and outpatient records, both pre and post delivery for the mother and infant from all locations.
Also specify that you want copies of all ABGs, cord blood studies, and all radiological and path reports for both mother and infant.
For all post delivery neuro-imaging studies for the infant, you will want to get a copies of all films.
Also ask for any and all copies of any “shadow” or duplicate or back up files kept in the individual departments, such as ob/gyn, peds, peds, neurology, etc.
Have the patient/parent take these requests for medical records to the medical record department at the facility where the care was given or the birth occurred. The person at the counter will inevitably request that the patient/parent sign a Kaiser generated medical record request that is very vague and non-specific.
Have the patient/parent sign this form also, but note on this form in writing that a patient-prepared request is also attached by staple, and that the specific documents listed thereon are requested. This way Kaiser cannot “redraft” their form to limit the records request. These records will have to be paid for.
It usually takes the Kaiser facilities about 3 to 6 weeks (not the statutory 15 days) to produce the above patient requested chart. The patient/parent may be asked why the want the records, but they don’t have to answer this question. Have the patient/parent call on a weekly basis to ask for the record copies.
After Kaiser finally produces the above set of records, then the attorney should request a second set pursuant to Evidence Code §1158 on his attorneys request form through a record copy service. Here the statutory time is 5 days, and the statutory rate is 10 cents/page.
This generates a second set of records, and surprisingly, the two sets obtained do not necessarily match in the end. Also look carefully, especially on the labor and delivery records for any additions to the chart, or changes, between the first and second set. It is not unknown for there to be “additions” to the second set once Kaiser is aware of scrutiny on a case.
Also, if the client has a personal calendar with appointment days listed on it, compare these dates with the Kaiser chart. Many, many times there are visits for which there are not records in the files. This most frequently occurs because the paper record for the visit was improperly filed in another patient’s chart.
If there is a date for which no record is produced, send out another request for that specific visit date, including any electronic records confirming an appointment on that date. You will frequently find visit records for other patients in a thick chart.
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