Help! Client Record Subpoenaed

[cocoa butter]

Hi all

I need some advice please. I have a client who first came to me about 2 yrs ago. I have seen her a total of 10 times during that period. About 6 mths after she first came she was involved in a MVA & had injuries such as a cracked sternum, bruising & whiplash as a result.
She has put in a personal injury claim with her lawyers & they have requested her records from me & I presume her Dr & chiro as well. As she was self referred originally I have never had any contact written or otherwise with her Dr or have not been given x-rays or any other info from the client as she really only had contact with Drs in hospital after her accident. All I have is my intake form with very brief abbreviated notes which are a little messy-I can understand them but I'm not sure others will find them legible I have never had to produce a client record for a claim before so I'm a little worried but I know legally I have to. What can I do? Touch them up? Rewrite them? Don't worry?

Help
Regards
OZ

 

[starsky_1212]

I'm not sure of the law where you are, but I wouldn't start rewriting, or touching up. I would think that as long as YOU know what your notes mean, and can translate them, that is fine. If you start rewriting or touching up, you could end up in a situation where they question what you have changed.

 

[Codys mom]

I'm not sure of the law where you are, but I wouldn't start rewriting, or touching up. I would think that as long as YOU know what your notes mean, and can translate them, that is fine. If you start rewriting or touching up, you could end up in a situation where they question what you have changed.

Agreed. Whatever you do, do not re-write them. If you do and it comes out, then the legitimacy of the records are definitely going to come in to question.

We used to do insurance billing and had plenty of clients who went to court. It is common practice for the attorneys to request all records. Just send them copy of what you have and let them worry about the rest. To be honest, your records really aren't the ones they will use. They will use the doctor's records to build their case and yours will only be used to substantuate the money they will ask for in the settlement to cover what the client paid for your services.

Angie

 

[Punkbmxer69]

I also agree, don't touch anything up. What you may want to do is add a list of what your abbreviations are though.

So, for example, if you use an R with a circle around it to mean "right", then have that and any other abbreviations written on an addendum.

 

[Hurdy]

I think that if you transcribe your notes to make them legible, if that is an issue, you should still send the originals. You don't want to bring into question the validity of the notes, and if something has been "lost in translation". When you start getting into the legal field, everything is questioned, and a CYA approach is often the best approach. I like the idea of an appendix of short forms you use.

 

[Bill M]

Do not transcribe them.
Do not rewrite them.

Just make copies and send them along.

I have been to several EBT's (examination before trial) for the hospital and IF they need a translation you will be deposed and asked to clarify.

The rule is, if they don't ask for it, don't offer it..also only answre what they ask. In this case they asked for records, give them records, nothing more.

They are most probably just building a paper record/trail to see if there has been a continuation of care.

Robyn

 

[Neetish]

I have been to several EBT's (examination before trial) for the hospital and IF they need a translation you will be deposed and asked to clarify.

:iagree:

You have much more hands on experience than I do, so I will defer to you, and then agree whole heartedly! *knock on wood* I've not yet had my files requested, so haven't had to deal with this. Only going on the limited law knowledge from my undergrad.

 

[Country Conservative]

I have had to supply client info twice. The last one, the woman was in a MVA, came in ONCE for a 30 min massage, and a week later, her lawyer sent me a request. All you can do is send in what you have. Thankfully, I have never had to go to court, they were both satisfied with the intake form I sent them.