02 May Medical Records in Court Proceedings: How They’re Used
When a civil or criminal trial touches on an injury or other health concern, the facts a legal team needs to prove to a judge and jury can be complex and difficult. How much pain was caused? Did pre-existing conditions or health concerns contribute to an outcome? What is the long-term recovery plan and potential?
Medical records offer a wealth of data both in court and during discovery, while trial strategies are investigated and developed. They detail facts that display narrative progression, cause and effect connections, patient compliance, and adherence to medical and ethical standards and institutional practices.
Automotive accidents, surgical malpractice, workers’ compensation—all of these and more rely on retrieving, organizing, and analyzing a complete set of medical records that comply with legal admissibility.
Why Medical Records Matter in the Legal Industry
Medical records have a rich evidentiary role in litigation. They can establish facts and illustrate narratives and details such as:
- Injury – Beyond simply identifying an injury, records can clarify pain levels, the degree of difficulty in completing routine tasks due to the injury, and, at times, details which speak to the cause of the injury. Records may include X-rays and other imaging to illustrate the injury.
- Diagnosis – The diagnosis of an illness or incident will be provided in technical language within medical records. Records can also reveal a trail of symptoms, steps, and referrals that includes ruling out other conditions and framing a diagnosis within the context of an individual’s whole health and diagnostic history.
- Treatment dates – Dates can be critical in helping clarify causation, and treatment notes will also identify the medical professionals at each point in a journey, the efficacy of treatments, and whether a patient followed recommended courses of action.
- Pre-existing conditions – Ideally, medical records in court proceedings provide a 360-degree view of an individual’s current health, including prior diagnoses, ongoing conditions, and past injuries and treatments, all of which can come into play in determining the true impact of the incident under litigation.
Medical record retrieval for lawyers is commonly used in a range of case types:
- Personal injury
- Medical malpractice
- Workers’ compensation
- Disability benefits
- Criminal cases, including determining the cause of death
Lawyers, of course, aren’t the only professionals in need of securing and researching these documents. With incidents that connect to several types of insurance policies—health care, medical malpractice, automobile, homeowners, disability, and business liability—medical record retrieval for insurance companies is also a frequent necessity.
Legal Situations Where Medical Records Are Required
Medical records serve as the only objective record of the patient’s condition and the care provided. Even if every health care professional involved in a patient’s care is available to testify directly, you would still look to medical records to document each step, observation, and action along the way that cannot be replicated by memory.
Legal situations and court proceedings that prompt medical records retrieval include:
- Discovery – Long before a trial date, a legal team enters the discovery phase, researching facts, deposing witnesses, and crafting a trial theory and arguments. Attorneys often start by requesting a wider or more complete set of medical records during this investigation period than will eventually be entered into evidence.
- Insurance claim validation – When individuals or businesses submit insurance claims that involve an injury or health condition, insurers need medical records to confirm the facts in the claim and make a determination of whether to pay out, reduce, or contest the claim based on policy coverage.
- Witness testimony – If expert witnesses in a trial cite medical records, both legal teams need them entered as evidence to either back up or impeach the testimony.
- Medical record quality – At times, the quality of a medical record is under direct review. In a matter of medical malpractice, for example, a poorly written and disorganized record can impugn the competence of care provided and, in of itself, offer proof of substandard care.
Legal Standards for Using Medical Records in Court
Medical records that are leveraged, cited, and entered into evidence must adhere to several standards. These include:
- Relevance – The record must pertain directly to the case—not, for instance, to a pattern of action by the patient or medical professional that isn’t specific to the issue at hand.
- Authenticity – The contents must be verified as authentic, meaning that the health care providers who entered content in the record had the legal authority to do so. A medical witness’s testimony, therefore, will typically begin by attesting to the licensure and education of the witness at the time they contributed to the medical record.
- Admissibility – Medical records must follow evidence rules and avoid hearsay exclusions. The two professional areas—medical and legal—each have different guidelines for attending to this type of information. For example, medical records may contain second- or third-hand testimony and opinions offered by family members that are included solely at the discretion of the health care team receiving them.
- Chain of custody and provider certifications – As with any critical piece of evidence, a medical record must be proven to enter into the court record with a clear chain of custody identifying where and how it was created, stored, and handed off prior to arriving in the courtroom. Today, this typically incorporates a digital trail of timestamps and handling as well as certifications for both digital and physical media.
- Redaction requirements – Medical records can be bloated with multiple layers of information that include a significant amount of sensitive, irrelevant, or prejudicial details that must be redacted before relying on them in court.
The legal standards above are based on the widely used Federal Rules of Evidence, but there may be additional jurisdiction-specific requirements to meet at state or local court levels.
How Legal Teams Use Medical Records Strategically
Exactly how do medical records contribute to a legal strategy? They can serve many goals and steps along the discovery, case development, and trial processes, including:
- Building case timelines – Medical records are intrinsically arranged by date in a sequence of events, symptoms, appointments, treatments, and results, making them critical to developing an overall case timeline.
- Reconstructing events – In addition to offering the data to populate a narrative timeline, medical records often contain rich details that help reconstruct events, such as subjective reporting of pain levels, provider reporting on the appearance and demeanor of patients at the time of their interaction, and x-rays, ultrasounds, photos, and other imaging.
- Corroborating other evidence – Medical records contain a plethora of dates, events, and other facts that can be cross-referenced and used to corroborate details provided in other documents or testimony.
- Supporting damages claims – Medical records are vital to helping apply a facts-driven framework to a subjective claim of pain and suffering. They also assist in understanding the costs to date and the projected costs of treatment and recovery from injury.
- Challenging opposing arguments – Medical records can be leveraged to challenge the opposition’s arguments, witnesses, or less definitive evidence. For instance, as the ultimate authority of an individual’s care, medical records can impugn a provider who testifies to acts or recommendations that are missing from or contraindicated by the record.
- Identifying medical expert opportunities – During discovery, medical records provide information on key health care providers who can be called upon to provide testimony. If their care or decisions are at issue, medical records can help guide decisions on engaging outside experts to analyze and speak to their efficacy or lack thereof.
The Value of a Medical Record Retrieval Partner
Legal and insurance professionals who value efficiency typically opt to partner with experts in medical record retrieval services. Engaging a professional firm can secure:
- Fast turnaround – Acquiring medical records, particularly from multiple sources, can take time and ongoing oversight. Health care providers and institutions each have unique systems and requirements related to record requests, and it’s the responsibility of the requesting party to resubmit and actively follow up on requests to avoid lags that can delay case progression.
- HIPAA compliance – HIPAA compliance requirements are complex and require careful handling of the technology and practices around all types of medical records. A specialized firm typically includes compliance professionals who stay on top of changing regulations and protocols.
- Accuracy – Retrieval experts know exactly what to check and review when records arrive, ensuring records are thorough and there are no missing pages, signatures, or certifications.
- Efficiency – Utilizing a specialty firm increases medical records efficiency and reduces the burden on legal teams, allowing them to focus on case strategy and preparation.
Make Medical Record Retrieval an Advantage in Litigation
When legal cases involve personal injury or health care treatment, medical record management is critical to build a case strategy and take a legal matter to the courtroom or negotiation table. They clarify timelines, identify causation, and help prove key facts.
Getting your hands on the right records at the right time, however, can be a challenge—that’s where secure, streamlined medical records retrieval software solutions become part of your legal strategy. Consider using a trusted partner like American Retrieval to access accurate, court-ready medical records efficiently and compliantly.
Sources:
LSU Medical and Public Health Law Site. Medical Records as a Plaintiff’s Weapon. https://biotech.law.lsu.edu/map/MedicalRecordsasaPlaintiffsWeapon.html
Louisiana State University Climate Change and Public Health Law Site. Medical Records in Litigation. https://biotech.law.lsu.edu/books/lbb/x187.htm
United States Courts. Federal Rules of Evidence. https://www.uscourts.gov/forms-rules/current-rules-practice-procedure/federal-rules-evidence