A difficult delivery lives in a family’s memory as a series of frightening moments. The medical chart records something different: hundreds of timestamps, observations, medication entries, and clinical decisions. Reading those records can help explain what happened, when a baby’s condition changed, and how the care team responded. The chart alone doesn’t answer whether medical malpractice occurred. That question requires a careful review of the complete record and informed medical analysis.
For more than 50 years, we’ve supported families affected by birth injuries. At Schroeter Goldmark & Bender, we know how much weight families place on getting that review right.
If you have questions about your child’s medical records or suspect delivery negligence, contact us today at (206) 208-0318 to schedule a free, confidential consultation.
Why Medical Records Matter After a Birth Injury
Medical records create a clinical timeline that can begin with prenatal appointments and continue through labor, delivery, newborn treatment, and later developmental care. No single document tells the whole story. The maternal chart, newborn chart, hospital records, and later pediatric or therapy records may each hold a different piece of the picture.
Some records document events: a change in fetal heart rate, a medication dose, the time of delivery. Others document a baby’s condition, diagnosis, and treatment. To evaluate a possible claim, reviewers must also consider the standard of care: the level of care a reasonably careful health care provider would deliver in similar circumstances, and whether that care caused or contributed to an injury.
That connection is called medical causation. It asks whether the injury is medically connected to an act, omission, or delay. It does not ask simply whether the injury and a concerning event occurred around the same time. Drawing clinical conclusions from a single notation is a mistake no attorney or parent should make.
What Labor & Delivery Records May Reveal
Labor and delivery records can show how labor progressed, when concerns appeared, and what actions followed. They’re often most important when a family remembers an emergency, a sudden shift in the room, or a prolonged period of concern before delivery.
Electronic fetal monitoring strips record a baby’s heart rate and contractions over time. Nursing flow sheets, maternal vital signs, cervical examination notes, and labor progress notes place those strips in context. Together, they may show whether staff documented changes in the baby’s status, the mother’s condition, or the progress of labor.
The medication administration record documents what was ordered and given, along with the recorded time of administration. In some deliveries, this includes medications used to induce or augment labor, manage pain, or address other clinical concerns. Timing matters, but any medication entry has to be read alongside monitoring data, orders, and the patient’s overall condition.
Physician and midwife notes document assessments, recommendations, and decisions about intervention. Delivery notes, operative reports, and anesthesia records may identify when a cesarean, assisted delivery, or other intervention was considered and performed. Communication entries can also clarify when a provider was notified about a concern.
An abnormal finding, a response that appears delayed, or conflicting descriptions across records may justify closer review. But an entry that looks concerning doesn’t prove that a provider failed to meet the standard of care. The significance of any record depends on the medical circumstances known at that moment, not only on the outcome.
What Newborn & NICU Records May Reveal
Records created immediately after birth often describe a baby’s initial condition more precisely than a discharge summary written days later. These materials help establish the timing and severity of medical concerns, as well as the treatment provided after delivery.
Condition at Birth & Resuscitation
A neonatal resuscitation record may show the interventions used after birth: oxygen, ventilation, chest compressions, medications, or intubation. Apgar scores, which assess a newborn’s color, heart rate, reflex response, muscle tone, and respiratory effort shortly after birth, document the baby’s early transition. They’re useful clinical information, but they aren’t a standalone measure of whether an injury occurred or why.
Umbilical cord blood gases measure oxygen and acid-base status in blood from the cord at birth. Along with respiratory support records, seizure observations, and newborn medication records, these results may help clinicians assess whether a baby experienced distress. Their meaning depends on the complete clinical record and qualified interpretation.
NICU Treatment & Later Effects
A neonatal intensive care unit chart may contain daily progress notes, consultation records, imaging, laboratory results, treatment orders, and transfer decisions. These records can identify complications, suspected diagnoses, and the explanations providers recorded during the hospital stay. Imaging and laboratory findings may be important evidence of a medical condition, but they don’t always identify its cause on their own.
Later pediatric, neurology, therapy, school, and developmental records address a separate question: how the child’s condition affects daily life over time. They may document therapy needs, mobility limitations, communication challenges, assistive equipment, or future care recommendations. In cases involving significant ongoing needs, a life care plan (which estimates the care and support a person may require over a lifetime) may be considered when evaluating damages.
How to Read the Record Without Misreading It
Medical charts aren’t written as a single narrative for families. They’re created by many people, often quickly, for clinical communication, billing, and legal documentation. That means a chart can contain abbreviations, copied-forward language, late entries, incomplete pages, and terminology that needs explanation.
Timestamps deserve particular attention. A note may describe an earlier event but be entered later, and a discharge summary may condense days of care into a few sentences. The most reliable timeline usually comes from comparing electronic fetal monitoring strips, nursing notes, provider notes, medication administration records, operative reports, and newborn documentation against one another.
Differences between those records can matter. A nursing note may record a concern at one time while a physician note describes notification at another; a medication record may not align neatly with a labor note. A discrepancy can reflect a documentation issue, a difference in perspective, or something that warrants further investigation. It isn’t automatic proof of wrongdoing.
Medical experts are generally needed to interpret clinical standards, the significance of monitoring patterns, and whether an earlier intervention would likely have changed the outcome. Our attorneys can coordinate a review of the available evidence, but the medical questions still require medical support.
How Families Can Gather & Organize Records in Washington
Start by requesting records promptly and keeping each provider’s materials together. A parent is generally treated as a minor child’s HIPAA personal representative and may access the child’s records when consistent with applicable law, subject to exceptions. The mother’s pregnancy and delivery records are often just as important as the child’s.
Request these record categories:
- Prenatal Care Records: Office notes, test results, ultrasounds, referrals, and communications from pregnancy care.
- Maternal Hospital Records: Labor and delivery records, nursing notes, fetal monitoring strips, medication administration records, anesthesia records, delivery notes, and operative reports.
- Newborn Hospital Records: Resuscitation records, newborn assessments, cord blood gas results, laboratory results, imaging, medication records, and discharge materials.
- NICU Records: Daily progress notes, consultation records, respiratory support documentation, transfer records, and treatment summaries.
- Later Care Records: Pediatric, therapy, developmental, neurology, rehabilitation, school, and assistive device records.
Keep a simple log showing the provider, date requested, date received, and any missing materials. Washington hospitals must retain medical records for at least 26 years under RCW 70.41, though that doesn’t mean every requested document will be immediately available or included in an initial response. If pages are missing, ask whether records were stored separately, including fetal monitoring data, imaging, or laboratory materials.
Washington medical malpractice claims are generally subject to the time limits in RCW 4.16.350, including a three-year period from the act or omission or one year from discovery, whichever is later, with statutory exceptions. The applicable deadline depends on the facts, so families in Washington shouldn’t assume one date applies to every situation. Requesting records early preserves time for a meaningful review.
To discuss a potential birth injury case, contact our team at (206) 208-0318.