The Alvarez Law Firm
Documentation Guide

The Evidence That Builds a Scope Infection Case

A strong Olympus scope infection case is built on a clear medical timeline and the records that prove it. The good news: most of the work is on us, not you. The records we need live in the hospital's files and the FDA's databases, and we know how to request them.

What we ask of patients is what only the patient can give us: a written timeline of what happened, the records you already have at home, and your permission to go after the rest. This page walks through both halves of the picture.

Layer One

The Procedure Record — What Happened on the Day

Every endoscopic procedure generates a paper trail, even when it feels routine to the patient. The procedure record is the foundation of a scope infection case because it establishes the basics: when the procedure happened, who performed it, what kind of scope was used, and what the doctor saw.

The records that matter from the day of the procedure include:

  • The operative or procedure note. The doctor's narrative description of what was done. It identifies the type of procedure (colonoscopy, ERCP, bronchoscopy) and often references the type of scope used.
  • The device identification log. Most modern hospitals maintain a record of the specific scope used in each procedure, identified by manufacturer, model, and serial number. The FDA's Unique Device Identifier rule reinforces this requirement.
  • The anesthesia record. Confirms timing, the patient's vital signs during the procedure, and any complications. Useful as corroboration when the procedure note is sparse.
  • The discharge summary. Sums up the visit, including instructions and any follow-up plan. Often the only document a patient takes home from the visit.

Patients almost never have the device identification log at home. That record lives in the hospital's reprocessing or surgical services department, and it is one of the records we request first.

Layer Two

The Infection Record — What the Bacteria Were and How They Were Found

The infection record is the most important set of medical records in a scope case. It is what proves that the patient developed a serious infection and identifies exactly what bacteria were involved. Without these records, even a strong story is hard to turn into a case.

The key documents:

  • Culture and sensitivity reports. When a hospital identifies the bacteria causing an infection, the lab issues a "culture and sensitivity" report listing the organism and which antibiotics work against it. This document is the smoking gun that names the pathogen — for example, "carbapenem-resistant Klebsiella pneumoniae."
  • Hospital admission and discharge records. If the infection led to a hospital stay, the admission and discharge documents establish the timeline and the diagnosis as the hospital understood it.
  • Imaging studies. CT scans, MRIs, X-rays, and ultrasounds that show the location and severity of the infection — an abscess, pneumonia, cholangitis, organ damage. These visualize what the bacteria did to the body.
  • Infectious disease consult notes. When the hospital brings in an infectious disease specialist, that doctor's notes are usually the most carefully reasoned document in the file. They walk through the diagnosis, the treatment plan, and often the suspected source.
Layer Three

Treatment Records and the Patient's Own Account

Treatment Records

The treatment record establishes how serious the infection was and what was required to recover. It is the basis for what a case is worth, beyond the underlying liability question.

  • IV antibiotic regimens, including length and any drug-resistance complications
  • Hospital and ICU stays, with admission and discharge dates
  • Additional surgeries or procedures required to address the infection
  • Long-term outpatient follow-up: PICC lines, home infusion, infectious disease visits
  • Documentation of any organ damage, kidney injury, or other lasting harm

The Patient's Own Account

The records explain the medicine. The patient explains the human side. Both matter. What we ask patients to write down at home:

  • A simple timeline: procedure date, when symptoms started, when you were diagnosed
  • Lost work and lost income, including any disability time
  • Out-of-pocket medical costs not covered by insurance
  • Family impact: caregiving needs, missed events, changes to daily life
  • Photos of any visible signs of illness if you have them
  • A list of every doctor and hospital that treated you, with dates

None of this needs to be polished or formatted. A handwritten page is fine. What matters is that the timeline and the impact are written down before memories fade.

What's on Us

What the Firm Handles for You

Patients often ask whether they need to assemble everything before calling. The answer is no, and the reason is that the most important records are the ones a patient cannot easily get on their own. When we open a case, the firm takes responsibility for the records work that follows.

  • HIPAA records requests to every hospital, clinic, and laboratory that treated you, formatted to comply with federal law and the hospital's own forms.
  • Device identification — pulling the make, model, and where possible the serial number of the scope used in your procedure from hospital reprocessing logs and FDA UDI records.
  • FDA MAUDE searches for adverse event reports tied to the same scope model, hospital, and time window as your procedure.
  • Medical-legal review by Herb Borroto, M.D., J.D., who reviews the records as both a physician and a lawyer to identify deviations from the standard of care and points where the design defect can be tied to the patient's injury.
  • Expert engagement — retaining the infectious disease, gastroenterology, pulmonology, or surgical experts the case needs to support its conclusions in court.

All of this work is done at the firm's expense, not yours. Under our contingency fee arrangement, you pay nothing unless we recover money for you.

Frequently Asked Questions

Common Questions

The questions we hear most often from patients trying to figure out what to gather before calling.

What records do I actually need to call?

Nothing specific. You do not need any records to make the first call. A free case review is just a conversation about what happened. If we accept the case, we will guide you through what to gather and we will handle the formal records requests ourselves under HIPAA's right of access. The first call is the start of the process, not the end of it.

I do not have all my records. Can I still call?

Yes. Most patients we talk to are missing some or most of their records. Hospital records are not designed for patients to organize at home — they are scattered across departments, EHR systems, and outside labs. We send formal records requests on your behalf to every facility that treated you, and we typically end up with a more complete record than the patient could have assembled on their own.

How do I find out which scope was used in my procedure?

Federal HIPAA regulations give you the right to request your own medical records, and the FDA's Unique Device Identifier rule requires hospitals to log the specific medical devices used in your procedures. Together, those two rules give patients a path to identify the make, model, and sometimes the exact serial number of the scope used. The blog post on how to ask which scope was used walks through the exact letter to send and what HIPAA requires the hospital to give you.

Do I need to gather everything before I call?

No. The opposite, in fact. Calling first lets us tell you which records will actually help and avoid spending days chasing paperwork that will not move the case forward. The timeline you can write in 20 minutes — dates, hospitals, infections, treatment — is enough to know whether you have a case worth pursuing.

Will the hospital give me my records?

They have to. Federal HIPAA law requires hospitals and other health care providers to give a patient their own records on request, generally within 30 days. They can charge a reasonable copy fee but they cannot refuse a properly submitted request. If a hospital pushes back, that is when an attorney's letter usually clears the path.

Sources

Verified Public Sources

Every factual claim on this page is supported by a verifiable public source. Click any source below to read the original.

  1. U.S. Department of Health & Human Services — HIPAA Right of Access Official HHS guidance on the patient's right to obtain their own medical records, including the 30-day response requirement and the limited circumstances under which a request can be denied.
  2. FDA — Unique Device Identification (UDI) System FDA's UDI rule requiring manufacturers to label devices with unique identifiers and hospitals to log them in patient records. The legal foundation for identifying which Olympus scope was used in a specific procedure.
  3. FDA — Manufacturer and User Facility Device Experience Database (MAUDE) Public FDA database of adverse-event reports for medical devices, used to identify other reported infections tied to the same scope model and time window.
  4. American Hospital Association — Patient Rights and Records Access AHA guidance on patient access to medical records, summarizing both federal HIPAA requirements and common state-level supplements.

Last reviewed:

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Take Action Today

We Handle the Records Work For You

If you developed a serious infection after an endoscopic procedure, you do not need to assemble a case file before you call. Tell us what happened. We will handle the rest. No Fees Unless We Recover Money for You.

(305) 444-7675 Free Case Review