How do I obtain medical records from the nursing home where my loved one was injured?

If your loved one was injured in the nursing home that was caring for them, one of your first steps should be to request their medical records.

how to obtain medical records from a nursing home

It can be difficult to know how to obtain medical records from a nursing home, which is why we’re here to help. The experienced Chicago nursing home abuse lawyers at Horwitz, Horwitz & Associates have put together a guide for obtaining your loved one’s medical records.

Keep reading, then call us at (800) 985-1819 for a free consultation.

Families have the right to request & receive records

In Illinois, a resident has the right to request their medical records from the nursing home and to receive the records within 24 hours of the request, excluding weekends and holidays.

As a general rule of thumb, you do not need to, and should not, disclose to the nursing home why the records are being requested. If you are the legal representative of your family member in a nursing home, you must verify your identity and representative status.

However, if you’re a family member who wants to obtain the records, you’ll need a power of attorney to do so legally. (A power of attorney means you have been assigned as the legal representative of your family member.)

There is an exception to this rule. An exception to this rule is if your loved one died under the care of the nursing home. In this case, under Public Act 97-623, if there is no will in place at the family member’s time of death, a surviving spouse, adult child, parent, or direct sibling of the deceased can obtain the records.

Using medical records to prove abuse

Unfortunately, vulnerable elderly people living in nursing homes often suffer abuse at the hands of staff members who are meant to care for them. Thankfully, a negligent or abusive staff member can be held accountable through a nursing home abuse lawsuit, in which evidence is crucial.

If your loved one was injured in a nursing home, medical records can be used to prove that there was abuse. The following are types of medical records and the ways in which they can prove abuse.

Admissions evaluations

Admissions evaluations will show the medical status of the patient when they were admitted. This baseline for how they were doing when they arrived can be compared to their current health status.

Plan of care

These are comprehensive plans of how the patient will be cared for during their residency. These documents must be created and put into effect within 14 days of the patient’s admission to the nursing home facility. If the care that the patient has received is insufficient, or different from the plan of care, this may indicate abuse or neglect.

Hospital records

Records of the patient’s hospital stays, either just before or during their nursing home stay, can show the patient’s medical condition and if their condition got worse. Hospital staff are trained to notice signs of physical abuse, so any documented concerns may also be used as evidence.

Medication and treatment administration records

These records are some of the most important. Medication administration records (MARs) and treatment administration records (TARs) detail both the plans to administer medications and treatment and the way the administration was actually carried out by registered nurses at the facility.

This is important because sometimes there will be evidence that the medication and treatment were not administered correctly, frequently enough, or according to the plan.

ADL flow sheets

An ADL flow sheet describes the activities of daily living of the patient and how they were assisted by staff members. This is another important record because it shows the frequency with which patients were assisted with basic activities such as bathing, eating, walking, and moving.

If the ADL flow sheets show that a patient was not provided with sufficient or frequent assistance with basic tasks, this could show that the negligence of the nursing home staff was to blame for the patient sustaining an injury.

Minimum data sets (MDS)

Under federal mandate, nursing home facilities must use a tool known as a minimum data set (MDS) to assess and record important information such as the patient’s underlying medical conditions, needs for care, and capacity for basic functioning.

This information can provide more insight into the needs of a patient and prove that they needed a certain level of care that they may not have received.

Investigation reports

Nursing homes provide investigation reports to state health departments whenever a patient is seriously injured in the facility. These reports may indicate nursing home liability if a patient was injured.

Our nursing home abuse lawyers are ready to help

If your loved one was injured while under the care of a nursing home facility in Illinois, you need the best representation possible for them.

At Horwitz, Horwitz & Associates, we believe in advocating and getting justice for those who were abused in nursing homes. It can be difficult to know you and your loved one’s rights in this situation, but we can help. We will walk you through how to obtain medical records from a nursing home and more.

Call (800) 985-1819 to schedule your free case consultation with an experienced Chicago nursing home abuse lawyer.