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Entry in Regular Course of Business

The first requirement is that the entry be made in the regular course of business. The medical records protocols, and the hospital bylaws in general, establish the limits of the regular course of business for the hospital. For a health care provider, this includes medical care, keeping medical records, and complying with state and federal health laws. Entries in the medical record that do not pertain to the rendering of health care will not be considered to have been made in the regular course of business. For example, if a patient seeks medical care after being involved in an automobile accident, the patient's physical condition, as described in the medical records, will be admissible as evidence in a legal proceeding. The patient's description of the accident, however, even if entered into the medical record by the attending physician, would not be admissible in court because the regular course of business of the health care provider does not include investigating automobile accidents. Thus, the medical information would be allowed into court under the business records exception, but the information about the accident would be excluded from the courtroom as hearsay. It would not fall under the business records exception because it was not recorded in the regular course of business of the hospital. In general, the hospital should discourage health care providers from making entries into the medical record that are not directly concerned with the provision of medical care or with legal matters, such as guardianship status, that are necessary to the rendering of medical care.

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