Medical Records and Evidence in Korean Malpractice Cases

In Korean medical malpractice cases, medical records are everything. They are the primary evidence of what happened, when it happened, and whether the care provided met the standard. Understanding what records exist, how to obtain them, and how they are analyzed is essential for any patient considering a malpractice claim.

What Records Should You Request?

A complete set of medical records includes: admission and discharge summaries, physician progress notes (daily notes from each treating physician), consultation reports from specialists, nursing records (vital signs, medication administration, patient observations), physician orders (medication orders, test orders, treatment instructions), diagnostic imaging reports (radiology, CT, MRI, ultrasound) — and the images themselves, laboratory results, operative reports (detailed accounts of surgical procedures), anesthesia records, informed consent forms, and discharge instructions. Request everything — do not assume certain records are irrelevant. What appears minor (a nursing note about a vital sign change, a delayed lab result) can be the key to proving negligence.

How to Obtain Your Medical Records

Under Korean law, patients have the right to access their medical records. To obtain records: submit a written request to the hospital's medical records department, specify that you want your complete records (not just a summary), bring identification (passport for foreign nationals), and if the hospital delays or refuses, your attorney can demand the records through formal legal procedures. Hospitals are required to provide records, and unreasonable refusal can itself be used as evidence of obstruction in a subsequent malpractice case. You may need to pay a copying fee, but this is typically modest.

How Attorney-Doctors Analyze Medical Records

Medical records analysis for malpractice requires both medical knowledge and legal understanding. Our attorney-doctors review records looking for: deviations from established clinical guidelines, gaps in documentation (missing notes often indicate missing care), inconsistencies between different records (the physician's note says one thing, the nursing record says another), delays between test ordering and test performance, failure to act on abnormal results, medication errors (wrong drug, wrong dose, wrong route, wrong time), and evidence of communication failures between medical staff. This analysis requires understanding not just what the records say, but what they should say if appropriate care was provided.

What If Records Are Missing or Altered?

Missing records can be as significant as the records that exist. Gaps in documentation may indicate that care was not provided. Altered records are a serious concern — in Korea, altering medical records to conceal negligence is itself a criminal offense. If you suspect records have been altered, your attorney can: compare records obtained at different times, request metadata from electronic health records, and seek expert forensic analysis. Evidence of record alteration significantly strengthens a malpractice claim.