What Medical Records Matter in an HIE Investigation?

After a diagnosis of hypoxic-ischemic encephalopathy, families are often told they can "request the records." What nobody explains is which records exist, what each one actually contains, or why a lawyer would want to read all of them rather than just the one that looks alarming.

This article walks through the record set one document at a time. It is written for parents, not for clinicians, and it deliberately stops short of telling you what any particular result means for your child — that is a question for a qualified medical reviewer looking at the whole chart. If you are still learning what the diagnosis itself means, start with our hypoxic-ischemic encephalopathy page.

Fetal Monitor Strips

Electronic fetal monitoring produces a continuous tracing of the baby's heart rate alongside the mother's contractions. It can be recorded externally, through sensors on the abdomen, or internally, through a scalp electrode. The result is a timestamped record of the labor as it unfolded.

The tracing is the closest thing the chart has to a minute-by-minute account, which is why it is usually the first thing a reviewer asks for. It is also the most commonly misunderstood document in the file. A tracing records a heart rate pattern. It does not measure the oxygen in a baby's blood. Certain patterns raise concern and call for closer attention, but interpreting them is a judgment exercise, and reasonable clinicians can read the same strip differently. We cover this in more depth on our fetal heart monitoring page.

One practical note: in many hospitals the tracings are stored in a separate monitoring system rather than in the written chart. A records request that asks only for "the medical records" can come back without them. Ask for the tracings by name.

Nursing Notes and Physician Communication

Nursing notes are the running narrative of the labor. They record what the bedside staff observed, when they observed it, and what they did about it — including when a physician was called, what was reported, and what instruction came back.

Reviewers read these notes against the tracing, because the two documents answer different questions. The tracing shows what the monitor recorded. The notes show what the people in the room saw and said. Where those two accounts line up, the picture is straightforward. Where they diverge, the divergence itself is worth understanding.

Medication Administration Records

The medication administration record lists what was given, at what dose, and at what time. In a labor and delivery chart it typically covers labor-inducing and labor-augmenting medications, pain management, and anything given during resuscitation.

Its value in a review is mostly chronological. Medication times are recorded precisely and are hard to reconstruct after the fact, so they anchor the timeline that the rest of the record is built around.

The Decision-to-Delivery Chronology

Families often expect to find a single document that says when the decision to deliver was made and when the baby was born. No such document exists. That chronology is assembled — from nursing notes, physician orders, anesthesia records, operating room logs, medication times, and the delivery record itself.

Building it is one of the more painstaking parts of a records review, and it is often where a review either finds something worth pursuing or does not. Where a delivery was expedited, the surrounding question is what was known beforehand and how the response unfolded. Our delay in C-section page covers how those cases are evaluated.

Cord Blood Gas Results

Shortly after birth, blood can be drawn from the umbilical cord and analyzed for its acid-base status. The result is a snapshot of the baby's condition at the moment of delivery, and unlike most of the record it is a measurement rather than an observation.

It is a narrow snapshot, though, and it has known limitations. Which vessel was sampled, how quickly, and how the sample was handled all bear on what the numbers mean. Cord gas results are read as one input among several, not as a verdict — and this article deliberately does not print threshold values, because a number pulled out of context tells a parent very little about their own child.

Apgar Scores and the Resuscitation Record

The Apgar score is assigned in the first minutes after birth and is probably the single most misread number in the chart. It is worth quoting the professional bodies directly. In their joint statement on the score, the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists write:

"The Apgar score provides an accepted and convenient method for reporting the status of the newborn infant immediately after birth and the response to resuscitation if needed. The Apgar score alone cannot be considered as evidence of, or a consequence of, asphyxia; does not predict individual neonatal mortality or neurologic outcome; and should not be used for that purpose. An Apgar score assigned during resuscitation is not equivalent to a score assigned to a spontaneously breathing infant."

That last sentence matters more than families expect. A score recorded while a baby is receiving active resuscitation describes a baby being supported, not a baby breathing independently — which is why the resuscitation record is read alongside the score rather than separately from it. That record documents what was done, in what order, and by whom.

NICU and Cooling Records

If a newborn was evaluated for therapeutic hypothermia, that evaluation generates its own paperwork: the neurological examination that determined eligibility, the temperature records across the cooling period, and the rewarming record.

The current clinical guidance describes cooling as a specialized therapy that requires neuromonitoring, neuroimaging, and planned follow-up of neurodevelopmental outcomes. In practical terms, that is why a cooled baby's chart usually contains imaging and brain activity monitoring — those studies are part of how the therapy is delivered, not extra tests ordered because someone suspected a problem with the care.

MRI and EEG — What Each One Answers

These two studies are often mentioned together and are sometimes assumed to be alternatives. They are not. They answer different questions.

An MRI images the structure of the brain — what the tissue looks like. An EEG records the brain's electrical activity — how it is functioning, including whether seizure activity is present. A chart can contain both, and a complete picture usually needs both.

What neither study does, on its own, is establish when an injury occurred or what caused it. Those are inferences, they require a qualified specialist, and they are drawn from the imaging together with the clinical course and the rest of the record.

Hospital Policies and Protocols

Hospitals maintain written policies covering how labor is monitored, when a physician is notified, how an emergency delivery is called, and when a newborn is transferred to a facility that provides specialized care.

These documents describe how a particular institution told its own staff to operate. They are useful context in a review, and they are requested for that reason. They are not, by themselves, the legal standard of care — that is established through qualified expert testimony, not by quoting a hospital handbook.

Why No Single Record Establishes Negligence

Everything above describes what documents show. Whether care fell short of what it should have been is a separate question, answered a separate way.

A diagnosis is not an answer about the care. Neither is a concerning tracing, a low Apgar score, an abnormal cord gas, an MRI finding, or the fact that a baby was cooled. Each of those describes a condition or an observation. The question of whether the response to that condition was appropriate requires reading the record set as a whole and having a qualified medical expert evaluate the care against the applicable standard.

This is the reason a records review is a real piece of work rather than a quick look. It is also why an honest review sometimes concludes that nothing went wrong — that a difficult outcome occurred despite appropriate care. Families deserve that answer just as much as the other one.

What Families Can Preserve Now

Whether or not you ever speak to a lawyer, a few things are worth doing while they are still easy:

• Request the complete labor, delivery and newborn records — not a discharge summary — and ask for the fetal monitoring tracings by name.
• Keep every piece of paper you were given, including discharge instructions, referral letters and follow-up appointment notes.
• Write down what you remember while it is fresh: times, what you were told, who told you, and who was in the room.
• Note the names and roles of the providers involved, and the dates and shifts if you know them.
• Keep records of the care your child has needed since — therapies, specialists, equipment and evaluations.

A strict statutory timeline applies to medical malpractice claims in Texas, and records become harder to assemble as time passes. Having a chart reviewed does not commit a family to filing anything. It answers a narrower question: whether there is something here worth looking at.

Frequently Asked Questions