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Medical Records in Litigation

The medical record is the basic legal document in medical malpractice litigation. A well-organized, well-written record is the best defense for the competent health care provider. A poorly-written, disorganized record is strong evidence of an incompetent health care provider. The poorly-kept record is not, in itself, proof of negligence on the part of the health care provider, but it is proof of substandard care.

Medical malpractice litigation is built around the medical record, which provides the only objective record of the patient's condition and the care provided. Records are particularly important for a physician's defense. It is the physician's responsibility to keep the medical record. The patient has injuries to show the court; the physician or other health care provider has only the medical records to prove that the injuries were not due to negligence. If the record is incomplete, illegible, or incompetently kept, this is the physician's failure. Although courts and juries usually give a physician the benefit of the doubt on ambiguous matters, this does not extend to ambiguities created by incompetent record keeping.

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