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Records Needed For Medical Malpractice Case

When filing a medical malpractice claim, strong documentation is one of the most important parts of building a case. The right records help show what care was provided, when it was delivered, and where the provider may have made a mistake. Our Ossining, NY medical malpractice lawyer can help you gather all the necessary documents. If you believe a healthcare provider’s actions caused harm, here’s what to focus on collecting.

Medical Records From All Treating Providers

The core of any malpractice claim starts with your medical records. These documents provide a timeline of your care and help us identify what went wrong. We request full records from all doctors, hospitals, and clinics involved in your treatment—both before and after the incident. Documents may include:

  • Admission and discharge notes
  • Test results and lab reports
  • Imaging records (X-rays, MRIs, CT scans)
  • Surgical reports and post-op notes
  • Progress notes from doctors and nurses
  • Prescription records
  • Emergency room documentation
  • Follow-up care summaries

It’s important to get records from each facility or provider, even if they were not directly involved in the mistake. Having the proper documents can help maximize your compensation, especially for medical malpractice that causes catastrophic injuries.

Referral And Consultation Notes

If you were referred to a specialist or saw another provider for a second opinion, those notes are useful as well. These records often show how one provider interpreted another’s actions, or what information was shared between offices. In some cases, these details help show that a delay or error occurred in communication. As a full-service law firm, we can handle all aspects of your claim, including gathering referral details.

Billing And Insurance Statements

Invoices, receipts, and insurance statements help document the financial impact of the malpractice. We collect all billing related to the injury, including:

  • Hospital and physician charges
  • Pharmacy receipts
  • Co-pay amounts
  • Out-of-pocket expenses
  • Explanation of benefits (EOBs) from insurance

Dealing with the insurance companies following medical malpractice can be stressful, even when you have insurance statements readily available. Just like with a car accident, having legal representation is recommended.

Employment And Income Records

If your injury caused you to miss work or affected your ability to earn income, we gather employment records to show the impact. This may include:

  • Pay stubs or direct deposit records
  • Tax documents
  • Letters from your employer confirming missed time
  • Disability paperwork if applicable

These help build a claim for lost wages or loss of future earning potential.

Personal Notes And Observations

We also encourage clients to keep a written record of their experience. This can include a journal of symptoms, daily pain levels, missed activities, or emotional changes. While these are not formal documents, they offer insight into how the injury has affected your daily life. These details are often helpful in explaining the human side of a malpractice claim.

At The Law Office of Jeffrey Weiskopf, we bring over two decades of experience with many satisfied clients. Contact us to talk about your situation and take the next step toward accountability and recovery following medical malpractice!

Jeffrey Weiskopf, P.C.

Call us today or submit a contact inquiry below.


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