How to Document a Medical Negligence Case to Strengthen Your Claim
Proper documentation is the cornerstone of any medical negligence claim. A detailed and structured gathering of evidence will significantly increase the chances of success in court or out of court. In this article, we delve into the process, with a step-by-step guide so you know how to document your case impeccably.
What is Medical Negligence?
Medical negligence implies that a healthcare professional fails, by action or omission, to meet the required standards of care, causing harm to the patient. The claim requires proving the following elements:
- Existence of a doctor-patient relationship (duty of care).
- Breach of duty (malpractice, error, omission).
- Actual harm or injury to the patient.
- Causal link between the negligent act and the harm suffered.
Importance of Documentation in the Claim
Without exhaustive documentation, a medical negligence claim often fails. The patient's account is not enough: the success of the case depends on clear and objective evidence. Proper documentation:
- Allows reconstructing the facts chronologically.
- Demonstrates the harm and its relation to the medical care received.
- Is essential for subsequent expert evaluation and damage assessment.
Fundamental Steps to Document a Medical Negligence Case
1. Request and Keep the Complete Medical Record
The medical record is the central element in healthcare documentation. In Spain, you have the right to request a full copy of your medical record, which must contain:
- Admission, progress, and discharge reports.
- Diagnostic test results: lab tests, images, biopsies.
- Informed consents (signed and dated).
- Treatment sheets, prescriptions, and guidelines.
- Nursing notes and any interconsultation.
- Surgical and anesthetic reports if an intervention occurred.
Tip: Request the medical record in writing and keep a receipt. The healthcare center is legally obliged to provide it.
2. Photographic, Video, and Material Evidence
- Clear photographs of injuries, scars, or resulting sequelae, with dates.
- If there are objects/materials involved (prosthetics, medications), keep them.
- Record videos to reflect the evolution or daily difficulties caused by the harm.
3. Document All Communications and Complaints
- Keep all emails, complaints, formal responses, and receipts.
- Record dates and content of phone calls or meetings with healthcare professionals or managers.
- Keep copies of complaint receipts submitted to the health center, insurance, or administrations.
4. Obtain a Medical Expert Report
The expert report is essential: it is written by a medical specialist concerning the harm suffered. It assesses whether there are reasonable indications of malpractice, quantifies the sequelae, and establishes the causal link. In most claims, this document is admitted and valued by judges as essential to support the claim.
5. Gather Witness Statements
- Request written testimonies from family members, companions, other patients, or even administrative or healthcare staff who observed the events.
- Record them in detail, signed, and dated.
6. Document Damages and Derivative Expenses
For compensation quantification, collect:
- Invoices for additional medical expenses, pharmacy, rehabilitation, and travel.
- Work leave reports, temporary or permanent disability reports.
- Receipts for psychological assistance.
How to Organize the Evidence for Your Claim
- Create a documentation index, ordering it chronologically.
- Separate medical documents, material evidence, communications, and expert reports.
- Scan all documentation and keep digital and physical copies.
- If you are going to consult a lawyer or expert, provide all the documentation organized: it will facilitate and expedite your defense.
Prescription Deadlines
Remember that there are legal deadlines for claiming, which in Spain usually range from 1 to 5 years depending on the chosen route (civil, criminal, administrative). Consult a specialized lawyer as soon as possible so that the documentation is valid and your claim does not expire.
Common Mistakes and Recommendations
- Not requesting the complete medical record or lacking the informed consent.
- Not acting quickly, allowing evidence to be lost or erased.
- Not collecting graphic evidence of the sequelae immediately.
- Not consulting a healthcare law expert before initiating claims.
Conclusion
The key to success in the face of possible medical negligence is to act quickly, gather all possible documentation, and seek specialized professional advice. A well-documented file not only facilitates the work of lawyers and experts but also conveys greater confidence to the insurer or the courts.
Contact our firm if you need help documenting and claiming medical negligence. Our team of lawyers and medical experts will study your case with the utmost rigor.