How to get your medical records, and your baby's

Ask for two separate sets

The mother's records and the baby's records are separate charts, often in separate systems, sometimes at separate facilities.

Request both. Name them separately. If a baby was transferred, request from both hospitals.

If you gave birth at one hospital and had prenatal care at a clinic, those are two more requests. Prenatal records are not usually part of the hospital chart.

The records request builder writes both letters. It runs in your browser and nothing you type is sent anywhere.

The documents to name, one by one

These are the documents that get left out unless you ask for them specifically. Each one is stored somewhere other than the main chart.

For the mother

• Complete prenatal record, including every visit, every ultrasound report, and all laboratory results.
• Group B strep screening result, with the date.
• Glucose screening results.
• Labor and delivery record and nursing notes.
• Labor flow sheet or partogram, showing dilation, station and contractions over time.
• Electronic fetal monitoring strips for the entire labor, paper and digital archive. This is the most commonly omitted document. Say "including the complete digital archive from the central monitoring system."
• Medication administration record and all infusion records, including oxytocin, magnesium and antibiotics with times.
• Anesthesia record. Almost always filed separately.
• Operative report, for any cesarean or assisted delivery.
• Shoulder dystocia note, if one occurred. Many units use a separate form.
• Estimated blood loss and any quantified blood loss record.
• Discharge summary and discharge instructions.

For the baby

• Delivery room record and newborn resuscitation record.
• Apgar scores at 1, 5 and 10 minutes.
• Cord blood gas results, arterial and venous.
• Complete newborn record, including all nursing notes.
• Complete NICU record, if there was a NICU stay, including daily notes and flow sheets.
• Every laboratory result with the exact time it was drawn. For bilirubin and glucose, say "with the time of each draw and the infant's age in hours."
• Medication administration record, including the weight used for dosing.
• All imaging reports and the images themselves, on disc or by electronic transfer.
• EEG reports.
• Newborn hearing screening result and the method used.
• Newborn screening blood spot results.
• Discharge summary and follow-up plan.

Filed apart from both charts

• Placental pathology report. This is a laboratory report, not part of either chart. Ask for it by name and say which laboratory if you know.

The records request pack prints this whole list.

How to send the request

Put it in writing. Email or a patient portal message is fine and creates a record.

Include:

• Your full name, date of birth, and the dates of care.
• Your child's full name and date of birth.
• The specific documents you want, by name.
• The format you want. Ask for electronic copies where possible.
• Where to send them.
• A request that they confirm receipt.

Keep a copy of everything you send, with the date.

If the facility has its own release form, use it and attach your list of named documents to it. Their form usually has a small box that does not fit the list.

Fees, deadlines, and what to do about them

The deadline

Thirty days. One 30 day extension is allowed if they tell you the reason and the new date. ^{1 2}

The fee

A reasonable, cost-based fee. It can cover the labor of copying, supplies, postage, and preparing an explanation if you asked for one. ¹

It may not cover searching for and retrieving the records. Federal guidance says so directly. If you are quoted a large "retrieval fee," that is worth questioning. ¹

Ask for the fee in advance, in writing.

Some states go further

A number of states set their own limits on what can be charged, and some are lower than the federal standard. Some also set shorter deadlines. Those rules are set by state law and change from time to time.

This site does not publish a per-state fee table, because we could not verify all 51 against a primary source during this build. See the sources policy for what that means. Your state health department or state medical board can tell you the current limit.

When the records come back short

This is common. It is usually a system problem rather than a refusal.

Compare what arrived against your list. Tick off each named document.

Write back naming what is missing. Be specific: "the request included the complete electronic fetal monitoring archive for 14 March. It was not in the disc I received."

Ask where a missing document is held. Monitoring strips, anesthesia records and pathology reports live in different systems, and the person handling your request may not know the others exist.

If you are told a record does not exist, ask for that in writing. That statement is itself part of the history.

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}

Read them before you decide anything

Records arrive as hundreds of pages in no useful order. See how to read your labor and delivery records, which goes through each document and explains what it says.

A few practical things

Ask for electronic copies. Cheaper, searchable, and easier to share with a specialist.

Ask for imaging on disc or by transfer, not just the reports. A radiologist reading the actual images can say more than a report allows.

Do it early. Records are easier to get while the birth is recent, and some systems archive or purge older material.

Getting records is not a legal step. They are your child's medical history. You will need them for specialists, for school, and for every new doctor for the next twenty years.

Keep the originals. Give copies to anyone who asks. Never give away your only set.