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August 26, 2026

Records We Collect for Kentucky Birth Injury Cases

Morrin Law Office
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Birth injury cases are built from records.

Parents may remember that nurses became worried about the fetal heart rate, Pitocin was stopped, an emergency C-section was discussed, or their baby was rushed to the NICU.

Those memories can be important.

But determining what medically happened usually requires putting objective records on a timeline.

Depending on the case, some of the most important evidence may include:

  • Complete fetal heart rate monitoring
  • Oxytocin administration records
  • Delivery-room resuscitation records
  • Umbilical cord gases
  • Cesarean and anesthesia timestamps
  • Vacuum or forceps documentation
  • NICU records
  • EEG
  • MRI
  • Bilirubin results
  • Newborn screening
  • Transport records

There is also an important distinction Kentucky families should understand:

Not every potentially useful piece of evidence is part of the ordinary patient medical record.

A patient’s chart may be available through an ordinary medical-record request.

Other information—such as a smart-pump event history, hospital staffing schedule, paging records, EHR audit trail, or operating-room availability data—may exist in a separate hospital system and require a targeted request, preservation effort, or formal litigation discovery.

Some internal peer-review and patient-safety materials may also be legally privileged.

This guide explains what to request, what may require additional investigation, and why each category matters.

Kentucky Patients Have a Statutory Right to Their Medical Records

KRS 422.317 provides that, upon a patient’s written request, a Kentucky hospital licensed under KRS Chapter 216B or a healthcare provider must provide the patient with a copy of the patient’s medical record without charge.

The statute allows a provider to charge up to one dollar per page for a second copy under the circumstances described in the law.

For a child under 18, KRS 422.355 generally provides a parent or authorized personal representative with access to the child’s health information maintained in the medical record, subject to applicable federal and state exceptions.

Mother and Baby Usually Have Separate Charts

This is easy to overlook.

The mother and newborn are separate patients.

Important evidence may therefore be split between:

Mother’s Chart

The maternal chart may contain:

  • Prenatal records
  • Labor notes
  • Fetal monitoring
  • Oxytocin
  • Anesthesia
  • Cesarean records
  • Vacuum or forceps records

Baby’s Chart

The newborn chart may contain:

  • Apgar scores
  • Resuscitation
  • Cord-gas results
  • Newborn examinations
  • NICU care
  • EEG
  • MRI
  • Bilirubin
  • Screening
  • Transfer records

A complete investigation often requires both.

Can You Ask for Electronic Records Instead of Paper?

Generally, yes.

Federal HIPAA access rules provide that when protected health information is maintained electronically, a covered healthcare entity generally must provide it in the electronic form and format requested if it is readily producible in that form and format.

If the requested format is not readily producible, the provider and patient can agree on another readable electronic format.

This is useful for large birth records.

Instead of receiving thousands of printed pages, families can ask whether records can be supplied electronically.

What “Electronic Format” Does Not Automatically Mean

It does not necessarily mean a hospital must provide every proprietary computer file in its original software format.

For example, a hospital may be able to provide:

  • A full fetal-monitor tracing as an electronic PDF
  • MRI images in DICOM format
  • A readable export of electronic chart records

but may not be required through an ordinary patient-access request to provide proprietary internal database files.

Ask for the most complete electronic version readily available.

Start With a Written Records Request

A written request creates a paper trail.

Depending on the provider, it can be submitted through:

  • The patient portal
  • Health Information Management
  • Medical Records
  • A hospital authorization form
  • A signed letter

Save a copy of:

  • The request
  • Date submitted
  • Confirmation
  • Responses
  • Records actually received
  • Follow-up requests for missing material

That documentation can matter later.

A Practical Sample Request

A parent can adapt language such as:

Please provide a complete copy of the medical record for the dates listed below, including all labor and delivery, nursing, physician, anesthesia, operative, newborn, NICU, laboratory, diagnostic, monitoring, and discharge records maintained as part of the patient’s record. Please provide electronic records in the requested electronic form where readily producible.

Please specifically include the complete electronic fetal heart rate and contraction tracing with timestamps and annotations, all medication-administration records, oxytocin documentation, anesthesia records, operative reports, cord-gas results, newborn resuscitation documentation, NICU records, laboratory results, EEG reports, radiology reports, and available diagnostic imaging.

If any specifically requested item is not maintained as part of the medical record or cannot be produced through the medical-record request process, please identify that item as unavailable through this request rather than silently omitting it.

The request should be adapted to the actual situation.

A separate request may be needed for each patient and facility.

Category 1: The Complete Electronic Fetal Monitoring Record

In many labor-related birth injury investigations, the electronic fetal monitoring record is one of the most important pieces of evidence.

It typically displays:

  • Fetal heart rate
  • Uterine contractions
  • Time
  • Monitor annotations

Clinicians may also document:

  • Baseline heart rate
  • Variability
  • Accelerations
  • Decelerations
  • Category I, II, or III classification
  • Interventions
  • Provider notifications

Do Not Request Only “Fetal Monitoring Notes”

The nursing notes contain interpretations.

They are not a substitute for the tracing itself.

Request:

The complete fetal heart rate and uterine-contraction tracing from the beginning of monitoring through delivery, including all available timestamps and annotations.

If internal monitoring was used, also request documentation concerning:

  • Fetal scalp electrode
  • Intrauterine pressure catheter
  • Placement
  • Removal

Why the Complete Strip Matters

ACOG’s current 2025 Clinical Practice Guideline on Intrapartum Fetal Heart Rate Monitoring emphasizes that fetal heart rate patterns are interpreted dynamically.

An expert may need to determine:

  • When the pattern changed
  • Whether variability was preserved
  • Whether decelerations became recurrent
  • Whether bradycardia occurred
  • Whether a Category II pattern deteriorated
  • Whether Category III criteria were met
  • What happened after interventions
  • How the tracing looked immediately before delivery

A handful of screenshots cannot reliably answer those questions.

What if Part of the Fetal Monitoring Is Missing?

Do not immediately assume that a missing section proves wrongdoing.

Possible explanations can include:

  • Signal loss
  • Monitor disconnection
  • Maternal repositioning
  • Transfer between rooms
  • Equipment issue
  • Archived data stored separately
  • Incomplete initial production

Ask whether the hospital maintains:

  • Archived electronic fetal-monitor data
  • Another monitor export
  • Paper backup
  • Central surveillance data

Kentucky’s KRS 411.167 expressly includes fetal heart monitor strips in its definition of “records” for that statute’s certificate-of-merit records provision.

Category 2: Oxytocin — Pitocin Records

When oxytocin was used to induce or augment labor, experts generally need more than a note stating:

“Pitocin running.”

The important questions concern dose and maternal-fetal response over time.

Medical-Chart Oxytocin Records

Request:

  • Oxytocin order
  • Medication administration record
  • Starting time
  • Recorded infusion rates
  • Every documented dose increase
  • Every documented dose decrease
  • Stop time
  • Restart time
  • Nursing assessments
  • Provider orders
  • Contraction documentation
  • Fetal heart rate documentation

Why These Records Matter

AHRQ’s perinatal oxytocin safety program emphasizes:

  • Standardized processes
  • Controlled infusion
  • Maternal monitoring
  • Fetal monitoring
  • Defined notification criteria
  • Response to clinical deterioration

The important legal question normally is not merely:

“What was the highest Pitocin dose?”

It is:

“What were the contractions and fetal heart rate doing as the dose changed, and how did clinicians respond?”

Smart-Pump Logs Are Different

Some modern infusion pumps can maintain electronic event histories showing information such as:

  • Programmed rate
  • Changes in rate
  • Start or stop events
  • Alerts
  • Alarms

These data can be valuable if they differ from or add detail to nursing documentation.

But a smart-pump event log should not automatically be described as part of the ordinary patient medical record.

Its availability can depend on:

  • Pump system
  • Hospital data architecture
  • Retention practices
  • Whether data are linked to the patient
  • Time elapsed since treatment

If pump history could matter, asking that relevant data be preserved promptly may be more useful than assuming it will appear in an ordinary chart download.

Category 3: Nursing Flowsheets and Bedside Documentation

Nursing documentation can contain much more information than the physician progress notes.

Request:

  • Labor flowsheets
  • Fetal assessments
  • Contraction assessments
  • Maternal vital signs
  • Position changes
  • Oxytocin changes
  • IV fluids
  • Provider notifications
  • Charge-nurse involvement
  • Newborn nursing records

Electronic flowsheets can contain observations at short intervals that never appear in a narrative note.

Category 4: Provider Notes and Orders

Request records from:

  • Obstetricians
  • Midwives
  • Residents
  • Fellows
  • Maternal-fetal medicine physicians
  • Anesthesia
  • Neonatology
  • Pediatrics
  • Neurology

Important records can include:

  • Progress notes
  • Consultation notes
  • Orders
  • Late entries
  • Addenda
  • Operative reports

The chart should be reviewed chronologically rather than reading each provider’s notes separately.

Category 5: Emergency C-Section Timing Records

When an emergency cesarean is questioned, the relevant timeline usually involves more than the phrase:

“Decision to incision.”

Potentially important times include:

  • First significant fetal deterioration
  • Nurse notification
  • Physician evaluation
  • Decision for operative delivery
  • Anesthesia notification
  • Operating-room notification
  • OR entry
  • Anesthesia-ready time
  • Skin incision
  • Uterine incision when recorded
  • Delivery

Where Those Times May Appear

Evidence may be scattered among:

  • Nursing notes
  • Obstetric notes
  • Anesthesia record
  • OR record
  • Surgical record
  • Fetal monitoring
  • Medication record
  • Neonatal resuscitation chart

Different documents may record slightly different times.

That is one reason the timeline should be reconstructed from multiple sources.

There Is No Universal 30-Minute Malpractice Rule

The records are not collected simply to determine whether 30 minutes passed.

There is no universal rule making every cesarean over 30 minutes negligent or every cesarean under 30 minutes appropriate.

The relevant questions include:

  • Why delivery was ordered
  • Fetal condition
  • Maternal condition
  • Whether the tracing recovered
  • Whether vaginal delivery was feasible
  • What occurred during the interval

Category 6: Anesthesia Records

Anesthesia documentation can contain detailed time information.

Request:

  • Preanesthesia assessment
  • Epidural placement
  • Epidural dosing
  • Spinal placement
  • Conversion to general anesthesia
  • Medication administration
  • Maternal blood pressure
  • Treatment of hypotension
  • Anesthesia start
  • Anesthesia ready
  • Operating-room documentation

In an emergency cesarean case, the anesthesia record can be essential for determining where time was spent.

Category 7: Forceps and Vacuum Records

When an operative vaginal delivery occurred, request documentation identifying:

  • Why the instrument was used
  • Fetal position
  • Fetal station
  • Instrument selected
  • Applications
  • Traction efforts
  • Vacuum cup detachments
  • Evidence of descent
  • Duration
  • Reason procedure continued
  • Reason procedure stopped
  • Whether another instrument was subsequently used
  • Whether cesarean delivery followed

SMFM’s operative vaginal delivery safety statement, reaffirmed in 2025, emphasizes the importance of specific documentation unique to forceps and vacuum delivery.

Do Not Assume a Universal “Three Pulls” Rule

Experts should review:

  • Progressive descent
  • Technique
  • Fetal status
  • Position
  • Instrument placement
  • Duration
  • Clinical circumstances

rather than treating one numeric threshold as an automatic malpractice test.

Category 8: Shoulder Dystocia Records

If shoulder dystocia occurred, request the specific shoulder-dystocia documentation.

Important information may include:

  • Time fetal head delivered
  • Time body delivered
  • When shoulder dystocia was recognized
  • Personnel present
  • Sequence of maneuvers
  • McRoberts maneuver
  • Suprapubic pressure
  • Internal rotation
  • Posterior-arm delivery
  • Maternal repositioning
  • Newborn condition

Shoulder dystocia itself does not establish negligence.

Documentation helps experts evaluate how the emergency was managed after it occurred.

Category 9: Umbilical Cord Blood Gases

Request both:

  • Umbilical arterial gas
  • Umbilical venous gas

when obtained.

Potential measurements include:

  • pH
  • pCO2
  • pO2
  • Base deficit or base excess

Cord gases can provide objective information about the newborn’s acid-base status near delivery.

They do not independently establish:

  • Asphyxia
  • Medical malpractice
  • Exact timing of brain injury

They must be interpreted with the rest of the record.

Category 10: Apgar Scores

Request:

  • 1-minute Apgar
  • 5-minute Apgar
  • Later scores when obtained
  • Individual component scores when documented

Apgar scores describe the newborn’s condition and response after birth.

They can help reconstruct the immediate post-delivery period.

An Apgar score alone does not establish that a child suffered hypoxic-ischemic brain injury.

Category 11: The Complete Newborn Resuscitation Record

The current authority is the 2025 AHA/AAP Neonatal Resuscitation Guideline.

Request documentation showing:

  • Initial breathing
  • Initial heart rate
  • Tone
  • Stimulation
  • Ventilation
  • Oxygen
  • Pulse oximetry
  • ECG when used
  • Intubation
  • Airway suctioning
  • Chest compressions
  • Epinephrine
  • Volume
  • Response to each intervention

Why Exact Timing Can Matter

The 2025 guideline emphasizes that newborns who are apneic, gasping, or persistently bradycardic despite appropriate initial steps should receive ventilation within the first 60 seconds after birth.

The record can help experts determine:

  • What the newborn needed
  • What was provided
  • Whether ventilation was effective
  • How heart rate responded

Meconium Records

Current guidance does not recommend routine suctioning solely because meconium was present.

If suctioning occurred, records may show whether:

  • The airway appeared obstructed
  • Ventilation was ineffective
  • Tracheal obstruction was suspected

That clinical context matters.

Category 12: HIE and Therapeutic-Hypothermia Records

If hypoxic-ischemic encephalopathy was suspected, request:

  • HIE neurological examinations
  • Gestational age
  • Cord gases
  • Early blood gases
  • Resuscitation
  • Cooling eligibility documentation
  • Cooling initiation time
  • Temperature records
  • Cooling-device records
  • Rewarming records
  • EEG/aEEG
  • MRI
  • Neurology notes
  • Neonatology notes

The AAP issued an updated therapeutic-hypothermia clinical report in January 2026.

For qualifying newborns at least 36 weeks’ gestation with moderate-to-severe HIE, current standard therapeutic hypothermia uses temperatures of approximately 33.5–34.5°C, is ideally initiated within six hours, and continues for 72 hours.

Cooling treatment itself does not prove the cause of encephalopathy or establish malpractice.

Category 13: EEG and Neonatal Seizure Records

If seizures were suspected or diagnosed, request more than the neurology consultation note.

Ask for:

  • Routine EEG reports
  • Continuous EEG reports
  • Video-EEG reports
  • aEEG records when used
  • Seizure annotations
  • EEG technologist notes
  • Antiseizure medication records

Ask Whether the Underlying EEG Data Are Available

The 2025 American Clinical Neurophysiology Society guideline supports cEEG when results are likely to affect care in newborns with:

  • Suspected seizures
  • Certain high-risk neurological conditions
  • Confirmed seizures requiring assessment of treatment response

Some neonatal seizures can be detected electrically without obvious visible movement.

When technically available and still preserved, the underlying digital EEG may permit an independent neurophysiologist to review:

  • Seizure onset
  • Duration
  • Burden
  • Response to medication

Availability and retention vary.

Category 14: Brain Imaging

When neurological injury is suspected, obtain the actual imaging whenever possible.

Potential studies include:

  • MRI
  • MRA
  • MRV
  • CT
  • Head ultrasound

The Image Is Different From the Report

A radiology report is the original radiologist’s interpretation.

The underlying images allow another qualified physician to conduct an independent review.

Ask radiology how the images are provided.

They are commonly distributed electronically or in standard medical-imaging formats.

Category 15: Bilirubin and Jaundice Records

For a severe jaundice or kernicterus investigation, request every:

  • Transcutaneous bilirubin result
  • Total serum bilirubin result
  • Direct/conjugated bilirubin result
  • Collection time
  • Result time
  • Phototherapy threshold calculation where documented
  • Phototherapy order
  • Phototherapy start time
  • Phototherapy stop time
  • Repeat bilirubin
  • Escalation-of-care documentation
  • Exchange-transfusion record

The 2022 AAP hyperbilirubinemia guideline bases important decisions on:

  • Bilirubin level
  • Gestational age
  • Age in hours
  • Neurotoxicity risk factors

A bilirubin result without its timestamp is therefore incomplete for meaningful analysis.

Category 16: Feeding, Weight, and Lactation Records

Feeding evidence can become important in jaundice, dehydration, hypoglycemia, and newborn-discharge cases.

Request:

  • Birth weight
  • Daily weights
  • Discharge weight
  • Percentage weight loss
  • Feeding flowsheets
  • Breastfeeding assessments
  • Lactation notes
  • Supplementation
  • Intake
  • Wet diapers
  • Stool output

A baby’s actual feeding course matters more than a generalized statement that the infant was “breastfeeding.”

Category 17: Sepsis and Infection Records

For suspected neonatal infection, request:

  • Maternal temperature
  • GBS status
  • Membrane-rupture timing
  • Maternal antibiotics
  • Newborn vital signs
  • Serial clinical examinations
  • Sepsis-risk assessment when used
  • Blood cultures
  • Antibiotic orders
  • Antibiotic administration times
  • CBC
  • CRP
  • Lumbar puncture records when performed
  • NICU notes

CBC and CRP can provide supporting information but do not independently diagnose or exclude early-onset sepsis.

Exact antibiotic administration times can be especially important when delay is alleged.

Category 18: Kentucky Newborn Screening Records

Kentucky’s current 902 KAR 4:030 requires covered hospitals and providers to administer or verify:

  • Blood-spot newborn screening
  • CCHD pulse-oximetry screening

before discharge, subject to specified exceptions and timing rules.

For most newborns who do not need an extended stay because of prematurity or illness, the blood-spot specimen is generally obtained between 24 and 48 hours.

CCHD pulse-ox screening is generally performed at 24 hours of age or older and before discharge.

Request the Actual Results

Ask for:

Blood-Spot Screening

  • Specimen collection time
  • Specimen identification
  • State laboratory result
  • Unsatisfactory-specimen notice
  • Repeat specimen request
  • Repeat result
  • Provider notification

CCHD Screening

  • Right-hand oxygen saturation
  • Foot oxygen saturation
  • Screening time
  • Repeat measurements
  • Pass/fail result
  • Follow-up
  • Echocardiogram when performed

Category 19: Newborn Hearing Screening

Kentucky also operates an Early Hearing Detection and Intervention program.

Request:

  • Initial OAE or AABR result
  • Repeat screen
  • Referral
  • Diagnostic ABR
  • Audiology notes
  • ENT records
  • Early-intervention records when applicable

A failed hearing screen does not itself establish permanent hearing loss.

Follow-up documentation may show what happened after the initial screen.

Category 20: NICU Records

NICU records can be enormous.

They are often central to causation and damages.

Request:

  • Admission note
  • Daily progress notes
  • Nursing flowsheets
  • Respiratory therapy
  • Ventilator settings
  • Blood gases
  • Medication administration
  • Procedures
  • Consultations
  • EEG
  • Imaging
  • Feeding and nutrition
  • Discharge summary

For long admissions, daily flowsheets may contain clinically important information not repeated in the physician progress notes.

Category 21: Transfer and Transport Records

When a baby was moved between hospitals, there can be three separate record sets:

  1. Referring hospital
  2. Transport service
  3. Receiving hospital

Ask for all three.

Transport Records May Show

  • Time transfer was requested
  • Accepting hospital
  • Accepting physician
  • Transport activation
  • Transport-team arrival
  • Condition at bedside
  • Treatments before departure
  • Ventilator or oxygen support
  • Medications
  • Departure
  • Condition during transport
  • Arrival

These records can fill gaps between the two hospital charts.

Kentucky Kids Crew — Lexington

UK HealthCare’s Kentucky Kids Crew provides hospital-to-hospital critical-care transport for neonatal and pediatric patients.

The team operates 24/7 using specialized ground and air equipment.

Norton Children’s “Just for Kids” Transport Team

Norton Children’s provides neonatal and pediatric inter-hospital transport through its “Just for Kids” Transport Team.

The service operates 24/7 by ground and helicopter.

If either service transported the child, request the transport record separately rather than assuming it is contained in the birth hospital’s chart.

Current Kentucky NICU Names Matter

Older medical and legal records may use names that have since changed.

Golisano Children’s at UK

Kentucky Children’s Hospital is now Golisano Children’s at UK.

The hospital operates a Level IV NICU in Lexington.

Norton Children’s Hospital

Norton Children’s Hospital operates a Level IV NICU in downtown Louisville.

A records request should use the facility name applicable at the time of treatment if known, but a current request can also identify the present health system.

Category 22: Outpatient Pediatric Records

Do not stop collecting records at NICU discharge.

Outpatient records can help establish when longer-term problems became apparent.

Request records from:

  • Pediatrician
  • Neurologist
  • Developmental pediatrician
  • Orthopedist
  • PM&R physician
  • Audiologist
  • Ophthalmologist
  • Other relevant specialists

Important evidence can include:

  • Developmental milestones
  • Muscle tone
  • Hand preference
  • Seizures
  • Hearing
  • Vision
  • Feeding
  • Referrals

Category 23: Therapy and Early-Intervention Records

For a child with permanent or long-term impairment, save:

  • Physical therapy
  • Occupational therapy
  • Speech therapy
  • Feeding therapy
  • Early intervention
  • Equipment evaluations
  • Orthotic records

These documents help show how an injury affects real-world function over time.

Category 24: School and Developmental Records

As a child grows, relevant evidence can include:

  • Developmental testing
  • Neuropsychological testing
  • IEP
  • School therapy
  • Academic evaluations
  • Adaptive-function assessments
  • Attendance related to medical treatment

These records can become important in understanding long-term educational and functional needs.

Operational Evidence: Important but Often Not Part of the Ordinary Medical Record

Some evidence can be extremely useful without being part of the chart produced under a routine medical-record authorization.

Potential examples include:

  • Smart-pump event logs
  • EHR audit trails
  • Paging records
  • Secure-message logs
  • Telephone/operator logs
  • Operating-room availability records
  • Staffing schedules
  • On-call schedules
  • Hospital policies
  • Transfer agreements
  • Equipment-maintenance records

Why the Distinction Matters

A parent who asks Health Information Management for:

“the complete medical record”

may receive exactly that while still not receiving any of these separate operational records.

That does not necessarily mean the hospital withheld medical records.

The information may be maintained by another department and governed by a different production process.

EHR Audit Trails

An electronic health record can maintain metadata concerning actions such as:

  • When an order was entered
  • When a result became available
  • When a note was created
  • When a note was modified

Audit information can sometimes help answer timing questions.

But an audit trail should not automatically be treated as part of every ordinary patient record release.

Its relevance and discoverability are case-specific.

Pager, Telephone, and Secure-Message Logs

These records can matter when a case involves disputed communication.

Potential questions include:

  • When was the obstetrician paged?
  • When was anesthesia called?
  • When was the operating room notified?
  • When was neonatology contacted?
  • When was a transfer center called?

Retention practices vary.

That can make early evidence preservation important.

Staffing and On-Call Schedules

A staffing case may require evidence identifying:

  • Labor nurses
  • Charge nurse
  • Obstetric coverage
  • Anesthesia coverage
  • Neonatal coverage
  • Operating-room staff

These schedules ordinarily are not patient medical records.

They may become relevant through formal investigation or discovery when staffing is genuinely at issue.

Hospital Policies

Potentially relevant policies may address:

  • Electronic fetal monitoring
  • Oxytocin
  • Tachysystole
  • Chain of command
  • Emergency C-section activation
  • Operative vaginal delivery
  • Shoulder dystocia
  • Neonatal resuscitation
  • Newborn screening
  • Discharge
  • Transfer

A hospital policy can be relevant evidence.

It does not automatically establish the legal standard of care.

Incident Reports, Root-Cause Analysis, and Peer Review Are Different

Families sometimes understandably ask:

“Can I get the hospital’s incident report about what happened?”

Not necessarily.

Kentucky’s KRS 311.377 can protect qualifying professional-review proceedings and records from discovery in civil litigation when the statutory requirements apply.

Federal patient-safety law can separately protect qualifying patient-safety work product.

That can affect materials created for:

  • Peer review
  • Quality review
  • Credential review
  • Certain patient-safety investigations

The Underlying Evidence Is Different

KRS 311.377 expressly states that its privilege does not prevent discovery or use of evidence, documents, or records that are independently discoverable outside the protected review process.

For example, an independently existing:

  • Fetal heart tracing
  • Medical chart
  • Staffing schedule
  • Original hospital policy
  • Imaging study
  • Medication record

does not necessarily become privileged merely because a quality committee later reviewed it.

The privilege analysis is document-specific.

Why Records Should Be Collected Early

Evidence does not necessarily remain available forever.

Medical charts may be retained under one set of rules while:

  • Device data
  • Paging logs
  • Video
  • Audit data
  • Other operational information

may have different retention periods.

Early investigation can help identify important evidence before routine data-management systems overwrite or delete material.

That does not mean families should send broad or accusatory demands for every internal document.

A targeted preservation strategy should be based on what actually matters to the case.

Kentucky’s Certificate-of-Merit Statute Makes Record Requests Especially Important

Under KRS 411.167, many Kentucky medical-malpractice actions require a certificate of merit with the complaint.

The ordinary certificate reflects review of the case and consultation with an appropriately qualified expert supporting a reasonable basis to file.

What if Requested Records Have Not Been Produced?

KRS 411.167 contains a specific provision for this situation.

If the claimant requested records of medical treatment from the defendants and those records have not been produced, the statute provides that the claimant is not required to file the certificate until 90 days after the records have been produced.

For that provision, the statute says records include, but are not limited to:

  • Paper records
  • Electronic records
  • Dictations
  • Video recordings
  • Fetal heart monitor strips
  • Imaging studies

That is one reason to:

  • Make requests in writing
  • Keep proof
  • Identify missing fetal strips and imaging
  • Document production dates

Important Deadline Warning

The certificate-of-merit records provision should not automatically be treated as an extension of the statute of limitations.

The filing deadline and certificate requirements must be analyzed together.

Kentucky Medical-Malpractice Deadlines

The current version of KRS 413.140, effective July 15, 2026, generally provides a one-year limitations period for covered negligence or malpractice actions against physicians, surgeons, dentists, and hospitals.

For covered malpractice claims, the statute includes a discovery rule and a five-year outside provision.

KRS 413.170 can materially affect certain claims belonging to minors.

But families should not assume:

“Every child’s claim can wait until age 18.”

Different rules can apply to:

  • Parents’ claims
  • Wrongful death
  • Estate claims
  • Governmental defendants
  • State institutions
  • State employees

UK HealthCare and the Kentucky Board of Claims

This distinction can matter on a records page because many severely injured newborns receive care through the University of Kentucky.

The University of Kentucky is a state institution.

Under KRS 49.070, certain negligence claims involving the Commonwealth, state agencies, or state employees acting within the scope of employment can fall within the Kentucky Board of Claims system.

KRS 49.120 uses separate filing deadlines and expressly limits the effect of ordinary minority tolling for Board claims.

That does not mean every claim involving UK HealthCare belongs before the Board.

Provider status and the specific defendant matter.

The practical lesson is simple:

Collecting the records is only the first step. The defendant’s legal status should also be identified early.

Why Complete Records Matter Under KRE 702

Kentucky’s current KRE 702, effective July 1, 2024, requires reliable expert testimony.

The proponent must demonstrate that the expert opinion is more likely than not:

  • Based on sufficient facts or data
  • The product of reliable principles and methods
  • A reliable application of those principles and methods to the case

Complete records matter because an expert who has only:

  • A discharge summary
  • A few fetal strips
  • A radiology report without the MRI
  • A final bilirubin value without earlier levels

may lack important information needed to form a defensible opinion.

How to Organize Thousands of Pages

Do not try to read a complex birth record only from page 1 through page 5,000.

Organize evidence into categories.

Build a Master Timeline

Use columns such as:

Time Maternal/Fetal Finding Medication Staff Action Delivery/Newborn Event
1:10 p.m. Recurrent decelerations documented Oxytocin 8 mU/min Repositioning —
1:16 p.m. Tracing remains concerning Oxytocin stopped OB notified —
1:31 p.m. — — Cesarean decision —
1:44 p.m. — — OR entry —
1:52 p.m. — — Incision —
1:55 p.m. — — — Delivery

This example is illustrative only.

It is not a medical or legal timing standard.

Keep an Index of the Record Set

A useful index may include:

  • Maternal hospital chart
  • Fetal monitoring
  • Anesthesia
  • Delivery
  • Newborn chart
  • NICU
  • Transport
  • EEG
  • Imaging
  • Pediatric follow-up
  • Therapy
  • Bills
  • School records

This makes it much easier to identify gaps.

What If Two Records Show Different Times?

That is common.

For example:

  • Nursing note says 3:16
  • Anesthesia record says 3:18
  • OR log says 3:17

Do not “correct” one document yourself.

Preserve the conflicting timestamps.

Experts and attorneys can determine whether the difference reflects:

  • Clock synchronization
  • Documentation delay
  • Retrospective charting
  • Different events
  • Simple rounding
  • Another explanation

Original evidence is more useful than a cleaned-up reconstruction.

Do Not Write on Original Paper Records

If you receive paper records:

  • Scan them
  • Preserve the originals
  • Make working copies
  • Put notes on the copies rather than the original pages

For electronic records:

  • Preserve the original downloaded files
  • Work from duplicates
  • Keep the original filenames where practical

Preserve Your Own Evidence Too

The hospital chart is not the only evidence.

Families should also preserve relevant material they already possess, such as:

  • Discharge paperwork
  • Appointment instructions
  • Patient-portal messages
  • Emails
  • Text messages
  • Voicemails
  • Photographs
  • Videos
  • Personal timeline notes
  • Calendars
  • Bills

Do not alter original files.

What Not to Do

Avoid trying to create evidence.

Do not:

  • Manipulate a baby to photograph an injury
  • Delay medical treatment to document symptoms
  • Secretly alter medical documents
  • Edit original images
  • Guess at times and present them as confirmed
  • Assume an omitted item proves a cover-up

Preserve what exists and separate confirmed facts from recollection.

Copy-and-Paste Kentucky Birth Injury Records Checklist

Mother’s Prenatal and Labor Records

  • Complete prenatal chart
  • Maternal-fetal medicine
  • Ultrasounds
  • Prenatal testing
  • Admission/triage
  • Full labor chart
  • Complete EFM strips
  • Contraction tracing
  • Nursing flowsheets
  • Obstetric notes
  • Midwife notes
  • Oxytocin orders
  • Medication administration record
  • Maternal vital signs
  • Cervical examinations
  • Provider notifications

Delivery Records

  • Operative vaginal delivery note
  • Forceps/vacuum details
  • Shoulder dystocia record
  • Cesarean decision time
  • Anesthesia
  • Operating-room chart
  • Skin incision
  • Delivery time
  • Operative report
  • Placental pathology when performed

Baby’s Birth Records

  • Apgar scores
  • Cord arterial gas
  • Cord venous gas
  • Neonatal resuscitation record
  • Early blood gases
  • Newborn examination

NICU Records

  • NICU admission
  • Progress notes
  • Nursing flowsheets
  • Respiratory therapy
  • Ventilator data
  • Medications
  • Consultations
  • Feeding
  • Laboratory testing
  • Discharge summary

Neurological Records

  • HIE examinations
  • Cooling eligibility
  • Therapeutic-hypothermia records
  • EEG
  • Continuous EEG
  • aEEG
  • MRI
  • MRA/MRV
  • CT
  • Head ultrasound
  • Neurology consultation

Jaundice Records

  • TcB
  • TSB
  • Collection times
  • Result times
  • Phototherapy thresholds
  • Phototherapy start/stop
  • Escalation
  • Exchange-transfusion records

Infection Records

  • Maternal infection data
  • GBS
  • Membrane-rupture duration
  • Newborn vital signs
  • Blood culture
  • Antibiotics
  • CBC/CRP
  • Lumbar puncture when performed

Newborn Screening

  • Kentucky blood-spot screen
  • Repeat screen
  • CCHD pulse oximetry
  • Hearing screen
  • Follow-up referrals

Transfer Records

  • Transfer request
  • Acceptance
  • Transport activation
  • Transport chart
  • Departure
  • Arrival
  • Receiving-facility record

Long-Term Records

  • Pediatrics
  • Neurology
  • PM&R
  • Orthopedics
  • Audiology
  • PT
  • OT
  • Speech therapy
  • Early intervention
  • Developmental testing
  • IEPs
  • Equipment

Operational Evidence to Discuss Separately

Where relevant, investigate whether the following exist:

  • Infusion-pump history
  • EHR audit trail
  • Pager logs
  • Secure-message logs
  • Staffing schedules
  • On-call schedules
  • OR logs
  • Hospital policies
  • Transfer agreements
  • Equipment records

Do not assume all of these are included in the patient-access right under KRS 422.317.

Some may need formal discovery, and some other internal hospital materials can be privileged.

Frequently Asked Questions About Kentucky Birth Injury Records

How do I get my medical records after a Kentucky birth injury?

Submit a written request to each hospital or healthcare provider.

KRS 422.317 generally entitles the patient to a first copy of the medical record without charge.

Federal HIPAA access rules also provide rights to electronic copies when the information is maintained electronically and the requested format is readily producible.

Can I get my baby’s records?

A parent or authorized personal representative generally has a right under KRS 422.355 to access a minor child’s medical record, subject to applicable state and federal exceptions.

Should I request the mother and baby’s records separately?

Usually, yes.

They are separate patients and commonly have separate charts.

What is an EFM strip?

An electronic fetal monitoring tracing records the fetal heart rate and uterine contraction pattern over time.

It can be central to evaluating fetal status during labor.

Should I request the entire fetal strip?

Yes.

Ask for the full available tracing from the beginning of monitoring through delivery, including timestamps and annotations.

Are fetal heart monitor strips legally considered records in Kentucky?

KRS 411.167 expressly includes fetal heart monitor strips within its definition of “records” for the statute’s certificate-of-merit records provision.

Will my regular medical-record request contain the Pitocin pump history?

Not necessarily.

The medication administration record and nursing documentation should be requested.

Separate smart-pump event data may exist outside the ordinary patient chart and may require a targeted preservation or discovery request.

What is an EHR audit trail?

It is metadata that can reflect electronic actions such as when certain orders, results, or notes were created or modified.

It should not be assumed to be part of every routine medical-record production.

Can I request the hospital’s staffing schedule?

You can identify staffing information as potentially relevant, but staffing and on-call schedules ordinarily are not part of the patient’s medical chart.

Obtaining them may require litigation discovery.

Can I request the hospital’s incident report?

You can ask whether additional records exist, but qualifying peer-review, quality, or patient-safety material may be privileged under Kentucky or federal law.

Underlying independently existing records can present different discovery issues.

Why should I get the actual MRI instead of only the report?

The underlying images allow another qualified physician to conduct an independent review rather than relying solely on the original interpretation.

Should I request the raw EEG?

Ask whether the underlying digital EEG is still available.

Availability and retention vary, but the data can sometimes permit independent evaluation of seizure timing and burden.

What neonatal-resuscitation guideline is current?

The current AHA/AAP neonatal-resuscitation guideline was issued in 2025.

Older references to the 2020 guideline should be updated when discussing current practice.

What neonatal EEG guidance is current?

ACNS issued its current evidence-based guideline on indications for continuous neonatal EEG monitoring in January 2025.

What records matter most in an HIE case?

Often important evidence includes:

  • Complete fetal monitoring
  • Delivery timeline
  • Cord gases
  • Resuscitation
  • Early blood gases
  • Neurological examinations
  • Therapeutic-hypothermia records
  • EEG
  • MRI

The exact records depend on the individual case.

What records matter most in a Pitocin case?

Typically:

  • EFM
  • Contraction tracing
  • Medication administration record
  • Oxytocin dose changes
  • Nursing assessments
  • Provider notifications
  • Relevant pump history where available
  • Delivery timeline
  • Cord gases

What records matter most in a kernicterus case?

A bilirubin-by-bilirubin timeline is particularly important, along with:

  • Feeding
  • Weight
  • Phototherapy
  • Hemolysis evaluation
  • Discharge
  • Follow-up
  • Readmission

What records matter most after a forceps or vacuum delivery?

Important records can include:

  • Fetal position
  • Station
  • Instrument
  • Traction attempts
  • Vacuum detachments
  • Descent
  • Fetal tracing
  • Newborn examination
  • Imaging

What if my records appear incomplete?

Send a written follow-up identifying the missing categories.

Keep the original request, the production, and the follow-up request.

Sometimes a missing item is maintained by a separate department rather than intentionally withheld.

How quickly does HIPAA require access?

Federal HIPAA rules generally require covered entities to act on an access request within 30 calendar days, subject to the rule’s permitted single extension in specified circumstances.

State and other federal rules can also affect particular requests.

Does requesting records extend Kentucky’s statute of limitations?

Do not assume so.

KRS 411.167 contains a special certificate-of-merit provision when requested treatment records have not been produced, but that provision should not automatically be treated as extending every statute-of-limitations deadline.

What is Kentucky’s malpractice deadline?

Current KRS 413.140 generally provides a one-year limitations period for covered private medical-malpractice claims, along with discovery language and a five-year outside provision.

KRS 413.170 can affect certain claims belonging to minors.

Different rules can apply to state entities and other claims.

Do experts really review all these records?

In a complex birth injury case, often yes.

Different experts may focus on different parts of the evidence.

For example:

  • Obstetric expert — labor and fetal monitoring
  • Neonatologist — newborn transition and NICU care
  • Neurologist — seizures and long-term neurological effects
  • Neuroradiologist — MRI
  • Other experts — depending on the injury

How Morrin Law Office Collects and Reviews Birth Injury Records

A thorough records investigation may involve:

  1. Identifying every hospital, physician, transport service, and follow-up provider.
  2. Obtaining the mother’s complete prenatal and delivery chart.
  3. Obtaining the baby’s complete newborn and NICU chart.
  4. Preserving the complete fetal heart rate tracing.
  5. Obtaining oxytocin and other medication-administration records.
  6. Investigating available pump data where relevant.
  7. Building the emergency-delivery timeline.
  8. Reviewing anesthesia and operating-room documentation.
  9. Obtaining forceps, vacuum, and shoulder-dystocia records when relevant.
  10. Obtaining cord gases and resuscitation records.
  11. Preserving MRI, ultrasound, CT, EEG, and other diagnostic studies.
  12. Building bilirubin, seizure, infection, or HIE timelines where appropriate.
  13. Obtaining Kentucky newborn-screening and follow-up records.
  14. Collecting NICU transport and receiving-hospital records.
  15. Identifying potentially relevant operational evidence that may exist outside the chart.
  16. Separating ordinary discoverable evidence from potentially privileged peer-review material.
  17. Comparing different timestamps rather than assuming one record is automatically correct.
  18. Organizing the medical evidence for qualified experts.
  19. Evaluating filing deadlines and defendant status early.
  20. Preserving proof of record requests relevant to Kentucky’s certificate-of-merit requirements.
  21. Collecting long-term treatment, developmental, educational, and functional evidence.

A large record set does not necessarily mean there is a malpractice case.

The purpose of careful record collection is to determine what actually happened and whether qualified experts can support a connection between the care and the child’s injury.

Talk With Morrin Law Office About Birth Injury Records

If your child suffered a serious injury during labor, delivery, or newborn care and you are unsure which records to request, Morrin Law Office can help identify and organize the evidence relevant to a potential Kentucky birth injury investigation.

Morrin Law Office
214 W. Main St.
Richmond, KY 40475
Phone: 859-358-0300

Sources

Disclaimer

This page provides general public information about medical records, evidence collection, Kentucky birth injury litigation, and related medical guidance. It is not medical advice or legal advice.

Not every item discussed on this page is necessarily part of a patient’s ordinary medical record or discoverable in litigation. Operational records may be maintained separately, retention practices vary, and qualifying peer-review or patient-safety material may be privileged.

Likewise, having extensive records does not establish medical negligence. Qualified experts generally must determine whether the evidence supports a departure from appropriate care and whether that departure caused or materially worsened an injury.

Medical guidance, hospital systems, privacy rules, record-retention practices, Kentucky statutes, filing requirements, and deadlines can change. Families with questions about a child’s current health should rely on qualified healthcare professionals, and families with questions about records, preservation, or legal deadlines should consider individualized Kentucky legal advice promptly.

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