When starting a medical malpractice case, the injured patient should provide their attorney evidence both of what their injuries are and of how they were injured. If gathering documents on your own is unfeasible, a qualified medical malpractice attorney can help you obtain the necessary documents.
The list below outlines the documents generally needed for medical malpractice cases:
- Medical records
- Medical bills
- Insurance and Medicare/Medicaid correspondence
- Death certificate and autopsy report
- Correspondence with adverse doctor or insurer
- Receipts for related out-of-pocket expenses
- Pay stubs or tax returns to show income loss
- Photographs of the injured person before and after the incident
Medical records are the most important documents for beginning a medical malpractice case. Records both of the negligent care at issue as well as treatment after the fact are usually required to evaluate a potential case.
Although some medical records and general literature are given to patients at discharge, to obtain your actual medical records you must submit a request for medical records to the relevant facility or doctor. As a patient, you are entitled to your own medical records, but the facility may charge a fee. Usually records can be produced digitally, which reduces costs.
The law allows injured patients to recover damages for medical expenses incurred as a result of medical malpractice. Your medical bills are a key part of proving your medical expenses, both past and future, and they should be provided to your attorney when you begin your case and subsequently if you continue receiving them.
Insurance and Medicare/Medicaid
When medical treatment is paid for by a health insurer or a government program like Medicare or Medicaid, explanations of benefits (EOBs) and bills are sent to the insured patient. It is important to keep this correspondence to establish what medical bills have been paid and by whom. Furthermore, health insurers and government programs like Medicare or Medicaid may be entitled to subrogation, i.e., repayment of medical bills they paid for your treatment. All such correspondence should be provided to your attorney.
Death certificate and/or autopsy report
If your case involves a wrongful death, a death certificate will be issued and should be provided to your attorney. If an autopsy was performed, the autopsy report will be extremely important and should also be provided as soon as possible.
Correspondence with doctor or insurer
Written correspondence with your doctor about your medical care, allegations of negligence, and/or resulting injuries may prove crucial to your case. Any written allegations you have made—including online—and the doctor’s corresponding response should be preserved. Similarly, if you have spoken orally with your doctor about your case or injuries, you should communicate the substance of such conversations to your attorney.
Communications about your case or the underlying medical issues may not come directly from your doctor, but could come from their insurer. If you have received any correspondence from your doctor’s liability or malpractice insurer—or from your own health insurer—you should provide it to your attorney.
Receipts for out-of-pocket expenses
Patients often incur expenses related to medical care that are not actually itemized in billing records. For example, prescription medications, over-the-counter medications, and medical equipment are expenses frequently borne by the patient directly. If you incurred such costs as a result of medical negligence, you should provide the corresponding receipts to your attorney.
Evidence of lost income
After suffering injury from medical malpractice, many patients find themselves unable to continue working their former job, or may become unemployable entirely. Damages are available for lost income or lost earning capacity, but documentary evidence is key. Pay stubs and tax returns establishing your previous income should be copied and provided to your attorney.
Photographs of the patient both before and after the injury or death help personalize the case and establish the human toll caused by negligence. Providing a glimpse of the personal life of the injured patient, and their friends and family, is always helpful in a medical malpractice case.