How to Get Your ER Medical Records in New York

Your Right to Medical Records in New York

Under New York Public Health Law (PHL) § 18, you have the legal right to access your medical records from any healthcare provider or facility in New York State, including hospital emergency rooms. This right applies to:

• The patient
• A parent or guardian of a minor patient
• A legal guardian of an adult patient
• The personal representative of a deceased patient (executor or administrator of the estate)

Hospitals must provide copies of your records within 10 business days of receiving a written request. Failure to comply can result in penalties.

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What Records to Request

ER Medical Record

The complete ER medical record includes:

1. Triage documentation — Time of arrival, presenting complaint, vital signs, acuity level (ESI score)
2. Physician notes — History of present illness, physical examination, assessment, and plan
3. Nursing notes — Ongoing assessments, interventions, medication administration, response to treatment
4. Physician orders — All orders including medications, labs, imaging, and consultations
5. Medication administration records (MAR) — What medications were given, when, and by whom
6. Laboratory results — Blood tests, urinalysis, toxicology, cultures
7. Radiology reports — Official interpretations of X-rays, CT scans, ultrasounds
8. Radiology images — The actual images (on CD or electronic format), not just the reports
9. ECG/EKG strips — Electrocardiogram tracings
10. Monitoring data — Vital sign trends, cardiac monitor strips, pulse oximetry
11. Consultation notes — Notes from specialists consulted during the ER visit
12. Discharge instructions — The instructions given to the patient at discharge
13. Registration/admission records — Demographic information and insurance details

Electronic Health Record (EHR) Audit Trail

The EHR audit trail is a critical document that is often overlooked. It shows:

• Who accessed the medical record and when
• What orders were entered and by whom
• What alerts were generated (allergy, drug interaction, dose checking) and whether they were overridden
• What modifications were made to orders or notes
• When the patient was identified for each action

The audit trail is essential for proving medication errors, failure to diagnose, and other ER negligence.

Incident Reports

Hospitals are required to create incident reports for adverse events under PHL § 2805-j. While the content of incident reports may be protected under New York's patient safety/quality assurance privilege, the existence of an incident report can be established. Your attorney can request confirmation that an incident report was created.

How to Request Your Records

Written Request

Submit a written request to the hospital's Medical Records Department (also called Health Information Management). Include:

• Your full name and any former names
• Date of birth
• Date(s) of ER visit
• Medical record number (if known)
• A clear description of the records you want (be specific — see list above)
• Your contact information
• Your signature
• A copy of your photo ID

Authorization Form

Most hospitals will ask you to complete an authorization form (HIPAA release). You can typically download this form from the hospital's website. The form must specify:

• What records you want
• The purpose of the request (you can state "personal use" or "legal purposes")
• The format (paper or electronic)
• Who is authorized to receive the records

Fees

Under New York PHL § 18, hospitals may charge reasonable fees for copying records. As of 2024, the maximum fees are:

• Paper copies: $0.75 per page for the first 250 pages, $0.50 per page thereafter
• Electronic copies: Actual cost of production (typically less than paper)
• Search fee: Not to exceed $5.00 (waived if records are provided within 14 days)
• Postage: Actual cost

If the Hospital Refuses

If the hospital refuses to provide your records or delays beyond 10 business days:

1. File a complaint with the New York State Department of Health at health.ny.gov
2. File a complaint with the Office for Civil Rights (HHS) for HIPAA violations
3. Your attorney can file a motion to compel under CPLR § 3121 during litigation

Special Considerations

Municipal Hospitals (NYC Health + Hospitals)

If your ER visit was at a municipal hospital (Bellevue, Elmhurst, Kings County, etc.), you may need to request records through NYC Health + Hospitals' central records office. Be aware that the 90-day Notice of Claim deadline is running while you wait for records — do not delay seeking legal representation.

Deceased Patients

If the patient is deceased, the personal representative of the estate (executor or administrator) can request the records. You will need:

• Letters Testamentary or Letters of Administration from the Surrogate's Court
• A death certificate
• Your photo ID

Minors

Parents or legal guardians can request records for minor patients. When the minor reaches age 18, only the patient (or their authorized representative) can access the records.

Psychiatric Records

Psychiatric records may have additional protections under New York Mental Hygiene Law § 33.13. A special authorization may be required.

Preserving Evidence: The Litigation Hold

If you are considering a malpractice lawsuit, your attorney should send a litigation hold letter to the hospital immediately. This letter instructs the hospital to preserve:

• All medical records
• EHR audit trails
• Surveillance video (ER waiting rooms often have cameras)
• Incident reports
• Quality assurance data
• Internal communications related to the patient's care

A litigation hold prevents the hospital from destroying or altering evidence. If the hospital destroys evidence after receiving a litigation hold, the court may impose sanctions, including adverse inference instructions (telling the jury to assume the destroyed evidence was unfavorable to the hospital).

Frequently Asked Questions

How do I get my ER medical records in New York?

Submit a written request to the hospital's Medical Records Department (Health Information Management). Include your full name, date of birth, date of ER visit, a description of the records you want, and a copy of your photo ID. Most hospitals also have an authorization form on their website.

How long does the hospital have to provide my records?

Under New York PHL § 18, hospitals must provide copies within 10 business days of receiving a written request. If they fail to comply, you can file a complaint with the Department of Health.

What is an EHR audit trail and why do I need it?

The EHR audit trail shows who accessed the medical record, what orders were entered and by whom, what alerts were generated and whether they were overridden, and when the patient was identified for each action. It is critical evidence for proving ER negligence, especially medication errors and failure to diagnose.

How much does it cost to get my medical records?

Under New York PHL § 18, hospitals may charge up to $0.75 per page for the first 250 pages and $0.50 per page thereafter, plus a search fee not to exceed $5.00. Electronic copies are typically less expensive. If you are represented by an attorney, the hospital may waive or reduce fees.

Can I get records for a deceased family member?

Yes, but you must be the personal representative of the estate. You will need Letters Testamentary or Letters of Administration from the Surrogate's Court, a death certificate, and your photo ID.

What is a litigation hold letter?

A litigation hold letter is a formal notice from your attorney instructing the hospital to preserve all evidence related to your case, including medical records, EHR audit trails, surveillance video, and incident reports. It prevents the hospital from destroying or altering evidence.

This article is for informational purposes only and does not constitute legal advice. Prior results do not guarantee a similar outcome. No attorney-client relationship is created by reading this article or contacting MDLaw Firm.