Records Request Pack

Request 1: the mother's records

• Complete prenatal record, with every visit, all laboratory results and all ultrasound reports
• Group B streptococcus screening result, with the date taken
• Glucose and gestational diabetes screening results
• Blood type, antibody screen and any Rh immune globulin administration record
• Complete labor and delivery record, including all nursing notes
• Labor flow sheet or partogram, showing dilation, station, position and contractions over time
• Complete electronic fetal monitoring tracings for the entire labor, including the digital archive from the central monitoring system
• Medication administration record and all infusion records, showing rate and time of every change
• Anesthesia record, with all timed entries
• Operative report for any cesarean or assisted delivery, including the type of uterine incision
• Shoulder dystocia note or form, listing each maneuver in order with times
• Estimated and quantified blood loss records
• Perineal laceration documentation, including degree and repair
• All vital signs, including every temperature reading with its time
• Discharge summary and the written discharge instructions

Request 2: the baby's records

• Delivery room record and complete newborn resuscitation record, with all timed entries
• Apgar scores at 1, 5 and 10 minutes
• Umbilical cord blood gas results, arterial and venous
• Complete newborn record, including all nursing notes and the newborn examination
• Complete NICU record, with daily progress notes and nursing flow sheets
• All laboratory results with the exact time drawn, and for bilirubin and glucose, the age in hours at each draw
• Medication administration record, including the weight used for dosing
• All imaging reports and the images themselves, on disc or by electronic transfer
• All EEG and amplitude-integrated EEG reports and tracings
• Newborn hearing screening result, including which method was used
• Newborn screening blood spot results
• Ventilator settings, blood gases and oxygen saturation records
• Feeding records, weights and growth charts
• Discharge summary, follow-up plan and all referrals made

Filed apart from both charts

• The placental pathology report. This is a laboratory report, not part of either chart. Name it separately and say which laboratory if you know. ³

Tracking sheet

Facility / date requested / response due / what arrived / what is missing

If the records come back short

1. Tick off what arrived against the list above.
2. Write back naming what is missing, referring to the item and the date of your original request.
3. Ask where a missing document is held. Different systems hold monitoring archives, anesthesia records and pathology reports.
4. If told a record does not exist, ask for that in writing.
5. If access is denied, federal rules give you the right to request a review of certain denials, and you can file a complaint with the Office for Civil Rights. ^{1 2}

The records request builder writes both letters for you, with all of these named.