The Medical Record as a Legal Document
The medical record is primarily a medical document, and secondly a legal document. It protects the rights and interests of the patient, the healthcare organization and the care providers. As a legal document, it provides information about the type and quality of care the patient received from the caregivers whose orders, progress notes and various other reports are included in it. The medical chart is crucial in preventing/mitigating the consequences of medical malpractice litigation. A good medical record is the best defense in such litigation. Usually admissible as evidence, they are the starting point in the lawsuit. In malpractice litigation, medical records review and analysis must be done with more intensity and careful scrutiny. Legality of the Medical Record – Criteria to be Met To be admissible as a legal document the medical record should meet certain criteria. These are: The record actually belongs to the plaintiff in the case. The record was prepared and maintained in keeping with all statutory requirements as well as the policies and procedures of the institution. The various medical documents that make up the entire medical record were prepared in concurrence with the events described in the documents or as close to those times as possible. The record was prepared during the regular course of business. The record was prepared by individuals who had direct knowledge regarding the events described in it. The medical record was prepared and completed before the litigation commenced. The documents contained in the record (original or duplicate) are of good quality and are readable and identifiable as regards content and source. The record was obtained legally. In legal proceedings involving medical malpractice, personal injury, workers’ compensation, product liability and so on medical records have a very significant role to play. The medical record has increased importance in malpractice litigation wherein the plaintiff alleges that the injury was sustained during the medical treatment or that a previous injury was worsened by the particular medical treatment. This is why medical record review and analysis becomes more concentrated and detailed in a medical malpractice case.
A medical malpractice lawyer accepts or rejects a case on the basis of its apparent merits. Attorneys for both sides will review and analyze the medical record (usually with the help of reliable medical review services) to understand its content and find out how useful it is to support his/her case. The reviewer will prepare a clear, concise chronology of the events described in the medical record and present these in a crisp summary report. The review and analysis of the medical chart provides various facts, data and questions that the attorney can use in drafting or answering interrogatories, in preparing depositions and at the trial. The medical record is a critical source of information in medical litigation. The review must therefore be done only by a competent review team that is experienced and knowledgeable in the complex language of the record and its various components. They must be able to identify pertinent aspects in the record that may be overlooked by someone not proficient enough in medical record review. A good review team will be able to interpret the information found in the records, identify missing information, and find the missing information thus providing the attorney with all details needed to prepare and argue the case.
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