How Are Medical Records Used In A Legal Proceeding?

by | Last updated on Dec 8, 2023 | Published on Sep 17, 2021 | Medical Record Review

In any medicine-related litigation, the medical record is the key evidence and chart review is indispensable to extract the medical proof from the records. For example, in a medical negligence claim, the medical records are essential because they provide insight into the clinical judgment the medical practitioner exercised at the time. A good medical record contains the key details of every patient encounter. It would provide information regarding relevant clinical findings, decisions made and actions agreed upon, and about those making and agreeing to these decisions. Besides this, the medical records also contain details about the drugs/treatment/investigation prescribed as well as who is making the record and when. Attorneys and their legal teams find medical review services very useful to extract all important evidence they need from the records and build their case.

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Medical Records That Are Reviewed for Legal Use

Progress notes, examination findings, monitoring and follow-up arrangements are all included in the records. Handwritten notes, electronic health records, lab reports, correspondence between healthcare professionals, imaging records such as X-rays, photographs, and recordings and printouts from monitoring equipment are all part of the medical chart. Once all the medical records are collected, they have to be reviewed. Most attorneys prefer utilizing a professional medical record review company for a comprehensive review process.

Medical records and their review have a unique legal standing. While they are the providers’ business records, they are also highly confidential and typically require the patient’s permission before they can be shared with another entity. Most US states have passed medical privacy laws that restrict the sharing of medical information without the patient’s consent. Exceptions are when the medical record is needed at the discovery stage of a lawsuit such as when the patient has filed a legal claim based on that medical data.

Legal Use

Medical Records and Their Use in Legal Proceedings

  1. Act as a Foundation of Evidence

Medical records form the basis of evidence in cases involving personal injury, medical malpractice, workers’ compensation, disability claims, and more. They provide a factual and chronological account of the claimant’s medical history, diagnoses, treatments, and prognosis. This factual foundation helps legal professionals establish a clear timeline of events, understand the extent of injuries, and evaluate the causal relationship between an incident and resulting medical conditions.

In a personal injury case resulting from a car accident, the plaintiff’s medical records describing immediate treatment post-accident, subsequent therapies, and expert medical opinions establishing a direct link between the accident and sustained injuries serve as the primary evidence. These records help establish the extent of physical harm and its long-term implications, forming the basis for the compensation claimed.

  1. Valid and Admissible Records Help Win the Case

Authenticity is crucial when presenting medical records in court. Legal professionals must ensure the records are properly authenticated to be admissible as evidence. This involves verifying the source, accuracy, and reliability of the records. Understanding the rules of evidence and procedures for introducing medical records is vital to prevent objections and preserve the veracity of the evidence presented in court.

Take for instance a medical malpractice lawsuit that involves contested medical records. The defense may challenge the legitimacy of certain entries in the chart, claiming they were added after the incident to support the plaintiff’s case. The plaintiff’s attorney can successfully authenticate the records by presenting expert testimony from treating physicians and other clinicians, confirming the accuracy of the entries based on their knowledge and signatures.

  1. Help with Expert Testimony and Interpretation

Legal professionals often collaborate with medical experts to comprehend the complex medical jargon, clarify diagnoses, and understand the implications of treatments or injuries. These experts play a significant role in presenting medical information in a language that judges, jurors, and other legal professionals can understand.

In a complex case involving alleged medical negligence during surgery, expert witnesses, including surgeons and specialists, are crucial. These experts analyze the patient’s medical records, explain intricate surgical procedures, identify deviations from standard practices, and clarify the correlation between the alleged negligence and the patient’s subsequent complications.

  1. Can Have Considerable Impact on Case Outcomes

The contents of medical records can significantly influence case outcomes. Thorough documentation of injuries, treatment plans, and the prognosis can fortify a plaintiff’s injury claim. Conversely, for defendants in medical malpractice cases, scrupulous medical records review may help disprove claims of negligence or establish alternative causes for a patient’s condition.

For example, consider a workers’ compensation case that involves a workplace injury resulting in permanent disability. Thorough documentation within the medical records, including diagnostic imaging, specialist evaluations, and rehabilitation plans, would convincingly support the severity of the injury and its lasting impact on the individual’s ability to work. A comprehensive medical chart can also significantly influence the compensation awarded.

  1. Must Be Used Maintaining Privacy and Compliance

Legal professionals must navigate stringent privacy laws, such as HIPAA in the United States, governing the disclosure and use of medical records. Understanding these regulations is vital to ensure compliance while accessing, handling, and sharing medical information during legal proceedings.

  1. Can Help Develop Visual Aids for Effective Presentation of the Case

Presenting medical records effectively in court can significantly impact how the judge or jury view the information. Using visual aids such as timelines, charts, and summaries can streamline complex medical information and enhance understanding.

A legal team may employ visual aids such as timelines and diagrams obtained from the medical records to prove the sequence of events, treatments administered, and the alleged medical negligence. This visual representation facilitates a clearer understanding for the jury, strengthening the argument presented by the plaintiff’s counsel.

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The Power of Medical Records

Medical records have tremendous power in legal proceedings, providing forceful evidence that can sway the direction of a case. The medical records must have clear, accurate, comprehensive, concise, objective, up-to-date, and legible documentation of patient care. Altered, incomplete, or missing medical records can be personally and legally harmful. Whether personal injury lawsuits, criminal cases, workers’ compensation cases, disability determinations, medical negligence or other injury cases, the medical record is the most important document available. They are generally admissible at a trial, and a good medical record can effectively communicate the patient’s status and progress in therapy. They have a role to play at every stage of the litigation process.

Legal professionals proficient in the acquisition, authentication, interpretation, and presentation of medical records can better construct compelling arguments, strengthen claims, and ultimately uphold justice within the legal system. By understanding the intricacies in the medical records with the support of medical record review services, legal professionals can harness this invaluable resource to advocate for their clients effectively and ensure a fair and just resolution in legal cases involving healthcare and personal well-being.

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