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Including a Doctor’s Chart into Evidence

Mar 15, 2015 | Medical Malpractice

When you have filed a medical malpractice lawsuit in the state of New York, there are number of ways of getting the doctor’s medical chart into evidence. One of the ways is known as a business record exception. This means, the doctor’s records kept in the ordinary course of business, when the doctor was treating this particular patient. Since the doctor keeps these records in the ordinary course of his business, we are allowed to enter such records into evidence.

Establishing Authenticity of the Records

Your attorney will also want to establish the authenticity of the particular records involved in the case. This is done during the doctor’s deposition, which is a question and answer session held under oath, before the trial. Your attorney will ask the doctor these typical questions to establish authenticity of the records:

· Have you brought along all of the patient’s records?

· Are these the original charts of the patient?

· Are there any charts, other than what you have brought today?

· Other than billing records, are all of the patient’s record that you recorded, present in this room today?

· When was the last time you reviewed these records?

· Do you have notes for this patient at any other place like your office and so on?

Your lawyer will ask these questions because he would want to know if there are any other notes regarding you that may not be contained in the records that are being presented.

Your lawyer might also want to authenticate the doctor’s handwriting and signature on the records by asking:

· Have you written and signed this particular record?

· Did you sign this record at this particular date and time?

· Why was the record signed at that particular time?

· Is that the patient’s signature above your signature?

· Is this the informed consent sheet?

Establishing the Purpose of the Records

Your attorney will confirm with the doctor that he has written the records in his own handwriting and that he wanted to record significant findings in the record. Secondly, your lawyer will establish that the purpose of the doctor noting down all these findings in the chart, was for him to refer back and know all the aspects he had found out about the patient during the physical examination, and the complaints the patient had made initially. The records will also contain information about the tests that were performed and their results.

Records are mainly kept so that the doctor can refer back to them, and if the patient is being treated by another doctor, then that doctor has access to all the information about what happened before. Your attorney will ask the doctor if he kept accurate and thorough records.

With such questioning, the doctor will be agreeing that the records are crucial and they form a part of his business practice. The questions asked by your lawyer to the doctor during the deposition will also establish that the records are authentic, accurate, and they have important information about the treatment given to the patient.