Documents are subject to cross-examination under the hearsay rule. Most
documents are hearsay because they record what others did and said, and are
generally maintained by someone who was not involved in matters in the
records. There is an exception to the hearsay rules for business records. For
medical care practitioners, the medical record is the key business record.
Medical recordkeeping procedures must fulfill the legal requirements of the
business records exception if a medical record is to be admissible in court. This
exception to the hearsay rule requires that the record meet four basic tests:
1. The record was made in the regular course of the business.
2. The entry in the record was made by an employee or representative of that
business who had personal knowledge of the act, event, or condition that is
being recorded in the record.
3. The record was made at or near the time that the recorded act, event, or
condition occurred, or reasonably soon thereafter.
4. The records were kept in a consistent manner, according to a set procedure.