Tag Archives: written discovery

Written Discovery – Part 1, Requests To Produce

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written-discovery-log“The claim is to seek recovery for injuries that the plaintiff believes were caused by the defendant’s failure to meet an established professional duty of care.”, was how I ended the post Written Discovery – Introduction (this link will open in a new tab of your current window), and now to begin this post on what to anticipate and to respond with the information typically requested in all medical-negligence cases and specific information related to the claim of professional or institutional negligence, in both situations consistently and efficiently to written discovery.

Health Information Management (HIM) / Medical Records (MR) practitioners normally assist such requests when they are required to assemble and reproduce all medical information that pertains to the patient, including medical records, letters/reports including films, drawings, diagrams, photographs, and electronic data. I shall write more about this on my next continuing post on written discovery.

I think HIM / MR practitioners need to be aware of other common information with respect to the care at issue in the lawsuit requested from the hospital management which may include from what I have encountered from my experiences:

  1. any quality improvement activities conducted
  2. identification of any hospital policies relevant to the care and treatment at issue
  3. information regarding the identification and employment status of individuals involved in the relevant care and treatment of the patient or who have knowledge of the medical treatment at issue in the lawsuit
  4. any hospital accreditation status e.g Joint International Commission (JCI) or Malaysian Society of Quality in Health (MSQH) accreditation
  5. medical-staff bylaws, policies, and procedures, or other documents that govern the scope of medical-staff practices

During the pendency of the lawsuit, hospitals may be required to seasonably supplement their written-discovery responses with new or additional information identified during the course of discovery. HIM / MR practitioners may also be required to further assist hospital management in providing any new or additional information identified to complete any supplemental discovery requests.

Written Discovery – Introduction

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written-discovery-logThis post is a follow-up to the subject of written discovery I talked about in the post JCI Standard MCI.20.1, ME 1 (Part 1) – risk management, in “The organization has a process to aggregate data in response to identified user needs.” (this link will open in a new tab of your current browser window).

I am writing from common knowledge and experiences and I must confess I am no legal authority but I have used facts in this post based on matters relating to public domain circulars and proceedings I had been part of.

In Malaysia and even in your country it is increasing common when individual healthcare providers and hospitals face a real threat of becoming defendants in malpractice lawsuits.

Some common potential-litigation warning signs of an impending malpractice lawsuit may include instances when (i) the hospital administration receives an executed patient authorisation for release of medical records produced by a lawyer and usually accompanied (if not at a later date) request for copies of medical records/medical report(s), ,films and billing records, (ii) when patient and/or family that is very upset about an unexpected or dramatic outcome sends in a written compliant or even heated verbal exchanges occur in the care area(s) or when the patient and/or family present themselves at the hospital administration, and (iii) when a letter is sent to the press and is published in the newspapers or a press conference is called by the aggrieved parties. Whatever the circumstances maybe, the requests for the production of documents and tangible items already signals that there is reasonable belief that a lawsuit may be filed.

I shall not cover a spoliation action, a type of action not yet a phenomenen in Malaysia when a patient can seek damages not for negligent medical care, but for a breach of the duty to preserve medical evidence from the loss of medical information like key medical records or films,  medical devices or instruments used during the care and treatment, and even the loss of non-medical information such as phone records.

In preventing a spoliation action and in general, I think Health Information Management (HIM) / Medical Records (MR) practitioners should always maintain health information, and communication protocols for preserving health information with effective medical information maintenance policies and procedures through consistent and established policies. Your actions and practices will help control unnecessary hospital litigation losses and increase efficiency when answering inquires from legal, regulatory, or accreditation agencies.

Before I write more on my next post on written discovery, I think some knowledge on some law terms is necessary.

In a civil action like for a medical-malpractice lawsuit, a claimant (“plaintiff”) will state the defendant’s actions, or omissions, which caused the claimant’s loss and files a civil claim (“lawsuit”) against the defendant(s) who usually are individual(s) doctors, hospital(s), and doctor or medical practice group(s).

The claim is to seek recovery for injuries that the plaintiff believes were caused by the defendant’s failure to meet an established professional duty of care.