After an intervention, a patient continues to have pain and does not understand why the medications administered were changed. In the hypothetical example, he suspects a mistake, but he does not have the necessary documents to discuss the matter with another doctor in an informed manner. The first step is to organize his medical information and request the relevant documents.

The suspicion of an error does not, per se, mean that malpractice has occurred. An undesirable outcome can have different explanations, which must be medically and legally analyzed.

Determine which documents you are missing

Through the „medical file”, patients can understand different documents: the patient record, the results of the analyzes, the imaging studies, the recommendations, the discharge documents, and the records of the treatment.

If the treatment took place in multiple units, each may hold a portion of the documents. Create a timeline of the consultations and admissions, then identify the unit and the period for which you need the information. For an imaging investigation, for example, it may be useful to request both the interpretation and the images, if available.

How to formulate the request to the medical unit

Article 24, paragraph (1) of Law No. 46/2003 recognizes the patient’s access to their own medical data. The access of another person is verified according to the rules of consent, representation, and, as appropriate, those specific to the deceased patient. Submit a clear request to the unit that holds the documents. Indicate the patient’s identity, the duration of the treatment, and the documents requested. Specify whether you want the documents in paper form or in an electronic format available, and how you would like to receive them.

If you are requesting the documents on behalf of another person, check what proof of your qualifications is required. For a deceased patient or a minor, particularities may apply; it does not mean that simply being related solves any access problems.

Keep the request, registration number or proof of shipment. If the response is incomplete, compare the received documents with the requested list and request clarification in writing.

What more evidence can be useful?

In addition to medical documents, they keep appointments, correspondence with the unit, medication receipts, and documents regarding expenses related to care. They record the symptoms and important discussions chronologically, distinguishing what you remember from what is documented.

A second medical opinion can help understand the treatment and the possible causes of the result. However, the documents must be evaluated in context; a single formulation alone does not establish the existence of an error.

Mistakes to avoid

Do not delay necessary care to collect evidence. If there are symptoms that require attention, the priority is medical evaluation.

Avoid sending sensitive documents to people who do not need them and do not publish the entire file on the internet. Medical data is personal, and an informed opinion can be obtained through a confidential exchange of documents.

Frequently asked questions

Do I have to prove first that there was an error in order to request the documents? In the application, it is useful to identify the documents and the period of treatment; the analysis of any errors is a separate matter.

Does the medical file automatically prove malpractice? No. The documents may be important for the evaluation, but the conclusion depends on the analysis of the documents and the circumstances.

A legal consultation can help organize documents and evaluate options, along with a specialized medical opinion.

Legal references: Law no. 46/2003, articles 21–24.

To analyze your situation, contact the Bucharest law firm: 0732 710 701 or vreau@avocatbucuresti.ro.