Tessa Quinn
Medical records are essential in personal injury, mass tort, medical malpractice, or health-related cases. They offer factual evidence, document a series of actions and decisions, and illustrate degrees of pain and suffering. However, they are some of the most protected documents used in trials, with strict privacy guidelines and regulations. To introduce hospital records in a trial, they must be properly authenticated and accompanied by a proper foundation. This involves confirming the accuracy of the records and that they belong to the individual in question. A qualified witness, often the custodian of the records or a healthcare provider, must testify to the authenticity and accuracy of the records. In some cases, opposing counsel can agree and stipulate to the authenticity and admissibility of medical records without the need for a witness. Additionally, the records must be relevant to the case and provide critical information that supports or refutes a claim.
| Characteristics | Values |
|---|---|
| Authentication | Testimony from the custodian of the records or a certification from a qualified third party |
| Admissibility | Must be relevant to the case and provide critical information that supports or refutes a claim |
| Hearsay exception | Statements made by a patient or healthcare provider for medical diagnosis or treatment |
| Expert witness | Medical records are commonly used in conjunction with expert witness testimony |
| Patient consent | Written consent from the patient is required to use their personal health information |
| Compliance | Must comply with privacy and security rules, e.g., HIPAA |
| Record accuracy | Must be presumed accurate and belonging to the individual in question |
| Record format | Authenticated copies should be maintained in their original record format |
| Record content | Records must be prepared by agents of the medical facility and indicate the records are trustworthy |
| Use of records | Establish a timeline of events, detail the extent of injuries, show the impact on physical functionality |
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What You'll Learn
Authentication and admissibility
The admissibility of hospital records in a trial depends on various jurisdiction-specific court rules and state and federal privacy guidelines, such as the Health Insurance Portability and Accountability Act of 1996 (HIPAA). In general, medical records are considered hearsay. However, they are admissible as an exception to the hearsay rule if they meet certain conditions under FRE 803(6), sometimes called the business records exception. This exception recognizes that hearsay evidence is more likely to be reliable when it is created in the course of regular business.
To qualify for this exception, medical records must first be authenticated and accompanied by a proper foundation. Authentication is the process of proving that the document is what it purports to be. This can be done by introducing testimony from the custodian of the records or by using a certification from a qualified third party (often defined by state statute). The custodian of records or another qualified person must certify that the copies are true and accurate copies of the original and that they are business records made in the regular course of business by a person with firsthand knowledge of the information.
In federal court, medical records and bills are admissible as business records without witness testimony if they are properly certified. In state court, state procedure and statutes generally permit the introduction of medical records and bills. For example, in Tennessee, T.C.A. § 24-7-122 provides that medical records, when duly certified by their custodian, need not be identified at trial and may be used as if they had been identified at trial by these persons.
To avoid disputes with authenticity and accuracy, it is important to follow jurisdictional guidelines on:
- Custodial, third-party, or other authentication in writing or through testimony
- Providing adequate time for the opponent to review and challenge the records
- Annotating, excerpting, or otherwise altering records for trial presentation
Additionally, it is important to review the records for any relevant information that may need to be investigated or clarified for accuracy, such as the inclusion of transferred records from prior healthcare providers or errors due to autocorrect, mistranslation, or form auto-fills.
In personal injury cases, medical evidence is crucial to proving or challenging causation and damages. Medical records can provide factual evidence, document a series of actions and decisions, and illustrate degrees of pain and suffering. They can also be used to prove medical care sought immediately following an incident, detail the degree, duration, and pain level of an injury, and show how an injury impacted physical functionality. In medical malpractice lawsuits, record acquisition and use can be particularly challenging, especially if poor or fraudulent record-keeping is among the claims.
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Privacy and consent
Medical records are some of the most protected documents used in trials. Their utilization depends on various jurisdiction-specific court rules and state and federal privacy guidelines, such as the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Before introducing medical records at trial, legal teams must ensure they follow the guidelines for HIPAA compliance and any state regulations related to record access, handling, and storage. Law firms can be held accountable and found liable for both deliberate and accidental violations.
HIPAA applies to physicians and other individual and institutional healthcare providers, including dentists, psychologists, hospitals, and clinics. It limits the circumstances under which these providers can disclose protected health information (PHI). PHI is any individually identifiable health information that relates to a patient's physical or mental health condition or treatment. Under the HIPAA Privacy Rule, an individual has the right to access PHI maintained about them by a covered entity in a designated record set. This may contain electronic or non-electronic PHI.
HIPAA permits providers to disclose PHI with the patient's written consent, provided that the Rule's particular content and other requirements are met. When the patient is a minor, the parent, guardian, or custodian is typically authorized to give written consent to disclose the child's health information. Disclosures of PHI without the patient's written consent are allowed under certain circumstances, including:
- To prevent or lessen a serious and imminent threat to the health or safety of a person or the public, if the disclosure is made to a person or entity able to prevent or lessen the threat.
- To report suspected victims of abuse to appropriate agencies.
- In response to a court or administrative order.
- In response to a subpoena or other lawful process in a judicial or administrative proceeding if appropriate steps are taken to notify the individual or obtain a protective order with respect to the information.
In some states, laws applicable to institutional healthcare providers (hospitals and clinics) are generally not as stringent as HIPAA. For example, in Massachusetts, laws that apply to hospitals and clinics operated by the Department of Mental Health (DMH) permit the disclosure of a patient's health information without their written consent only in very limited circumstances. These include disclosure at the request of the DMH, pursuant to a court order, or where the disclosure is determined to be in the patient's best interests and it is not possible or practical to obtain their written consent.
In federal court, medical records and bills are admissible as business records without witness testimony if the custodian of records or another qualified person certifies that the copies are true and accurate and were made in the regular course of business by a person with firsthand knowledge. In state court, state procedure and statutes generally permit the introduction of medical records and bills. For example, in Tennessee, medical records or reproductions of medical records, when duly certified by their custodian, physician, physical therapist, or chiropractor, need not be identified at the trial and may be used as if the records were identified at trial by these persons.
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Relevance to the case
Medical records are often pivotal in legal disputes, particularly in personal injury, mass tort, medical malpractice, or other health-related cases. They are essential in establishing a timeline of events, providing factual evidence, and illustrating degrees of pain and suffering.
In personal injury cases, medical records are crucial to proving or refuting causation and damages. They contain critical information about the plaintiff's injuries, treatment, and health history. For example, in a car accident case, medical records can show whether injuries were caused by the accident or existed beforehand.
Medical records can also be used to establish the nature and extent of a patient's injuries. For instance, in the case of McDowd v. Pig ’n Whistle Corp. (1945), hospital records were admitted to show the nature and extent of the plaintiff's injuries. Similarly, in a medical malpractice lawsuit, records can demonstrate reported symptoms, the presence or absence of diagnostic testing, and patient notifications.
In addition to providing valuable information, medical records must also meet specific requirements to be admitted into evidence. They must be properly authenticated, with their accuracy and belonging to the patient confirmed. This can be done through the testimony of a qualified witness, typically a custodian of the records or a healthcare provider. Alternatively, authentication can be achieved through a certification from a qualified third party, as defined by state statute.
Furthermore, medical records must comply with jurisdiction-specific court rules and state and federal privacy guidelines, such as the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Before introducing medical records, legal teams must ensure HIPAA compliance and follow relevant state regulations regarding record access, handling, and storage.
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Expert witness testimony
The admissibility of expert testimony is subject to certain requirements. Under FRE 702, an expert witness must be qualified to testify based on their education, training, or experience in the relevant field. They should also be able to provide opinions that are based on reliable methods and principles that are widely accepted within the scientific community. Their opinions must be relevant to the issues in the case and must assist the jury in understanding the evidence or determining a fact in dispute.
In Lamalfa v. Hearn, the Maryland Court of Appeals held that medical records could be admitted when relied on by an expert witness and the records satisfied the four conditions of Maryland Rule 5-703(b). The expert witness reviews the medical records and provides a written opinion regarding the standard of care and whether or not there has been a deviation from the standard. The expert may be deposed and provide recorded testimony under oath to the questions of attorneys from both sides.
To share records with a medical expert or expert witness, copies of these records should be made available. It is important to ensure that the sharing is secure and confidential, and an inventory of what records have been shared and when should be maintained. When sharing records, instructions are usually provided to the expert witness on the issues they should consider. The expert witness then provides their analysis or conclusions.
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Record retrieval and organisation
To retrieve medical records, legal teams must follow specific guidelines, including HIPAA compliance and state regulations related to record access, handling, and storage. Attorneys must also adhere to evidence guidelines for the specific jurisdiction. Before medical records can be used in court, the patient typically must give written consent for the use of their personal health information.
To ensure admissibility, medical records must be properly authenticated. This involves confirming their accuracy and that they belong to the individual in question. A qualified witness, often a custodian of the records or a healthcare provider, must testify to the authenticity and accuracy. Some records, like psychotherapy notes, may be protected by patient-therapist privilege.
To organise medical records effectively, legal teams can utilise a master key to track requests, files, review status, and usage. Standardising digital naming formats and syncing files across formats can improve accessibility. Relevant information from the records can be excerpted or cropped for trial presentations, ensuring compliance with court guidelines on evidence labelling and case preparation.
In summary, record retrieval and organisation are crucial steps in trial preparation, especially when medical records are involved. By following the necessary guidelines, legal teams can effectively retrieve, authenticate, and organise medical records to support their case strategy.
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Frequently asked questions
Authenticity and admissibility. Hospital records must be properly authenticated and admissible as business records.
Authentication is the process of proving that the document is what it purports to be. This can be done by introducing testimony from the custodian of the records or by using a certification from a qualified third party.
The business records exception recognizes that hearsay evidence is more likely to be reliable when it is created in the course of regular business. This exception allows medical records to be admitted as evidence without the need for witness testimony if the custodian of records certifies that they are true and accurate copies.
Some common challenges include obtaining written patient consent, complying with privacy laws such as HIPAA, ensuring accuracy and belonging to the patient in question, and interpreting medical terminology and context.
Hospital records can provide factual evidence, establish a timeline of events, detail the degree and duration of injuries, and show the impact on physical functionality. They can be crucial in personal injury cases to prove causality and calculate damages.
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