Entry in the Regular Course of Business
The first requirement is that the entry be made in the regular course of business. For a physician, the regular course of business is providing medical care, keeping medical records, and complying with state and federal health laws. The medical record will be admissible to prove the truth of activities related to the practice of medicine. Entries in the medical record that do not deal with the practice of medicine 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. However, if the physician also entered the patient’s description of the accident into the medical record, this would not be admissible because investigating accidents is not part of the regular course of business for a physician. Thus, the information about the accident would be excluded from the courtroom as hearsay.
In general, physicians should refrain from making entries into the medical record that are not directly concerned with the provision of medical care or with legal matters that are necessary to the rendering of medical care (for example, guardianship status or court orders bearing on the rendering of medical care).