Medical Records in Court Proceedings: Key Details

Cases that touch on medical conditions and injuries require proving causality and calculating degrees of responsibility and compensation, often amidst a convoluted mix of events, timelines, treatments, comorbidities, and other factors that medical records attest to. 

Organizing medical records for trial is a complex process, involving multiple sets of legal guidelines and jurisdictional rules. Below, we review key details attorneys need to understand before retrieving, analyzing, and entering medical records for legal proceedings. 

Importance of Medical Records as Legal Evidence

Medical records in court proceedings can make or break a case. They’re used to connect dates, actions, responsibilities, decisions, and communication relevant to an individual’s health care. 

Records can help prove facts such as: 

• Whether and when the correct testing was ordered for a timely diagnosis
• Where miscommunication or inaction occurred between a series of multiple healthcare providers
• Whether or not a patient received proper medical direction and followed it
• If an error occurred at an administrative, diagnostic, procedural, or other care level

To this end, medical records help in: 

• Medical malpractice lawsuits
• Worker compensation, wrongful death, and disability determinations
• Personal injury lawsuits against pharmaceutical and medical device manufacturers
• Any lawsuit where an individual’s physical, mental, or emotional health is a factor
• Insurance claims and disputes

Legal Standards for Admissibility of Medical Records

While they may be essential evidence in a case, medical records are some of the most protected documents used in trials. Their proper utilization depends on various jurisdiction-specific court rules and state and federal privacy guidelines, particularly the Health Insurance Portability and Accountability Act of 1996 (HIPAA). 

Prior to introducing medical records at trial, legal teams must do the following.

Ensure Compliance with HIPAA and Other Regulations

Before you start retrieving medical records, ensure your team follows the guidelines for HIPAA compliance for law firms and any state regulations related to record access, handling, and storage. These aren’t best-practice suggestions but legal responsibilities. 

HIPAA and other guidelines dictate: 

• Who can access what types of medical records and under what circumstances
• Limitations on redisclosure of records once obtained
• How health information is transmitted, retained, and stored

Law firms can be held accountable and found liable for both deliberate and accidental violations, including¹: 

• Violations ruled to be caused by lack of training
  • HIPAA training for employees must be documented (e.g., what, when, who)
• Inadvertent disclosure due to computer error, based on failure to:
  • Implement the required administrative, technical, or physical safeguards
  • Provide adequate security instruction to the computer user 

Follow Criteria for Admitting Medical Records in Court

In addition to privacy guidelines, attorneys must follow the evidence guidelines for the jurisdiction in which their case is presented. Federal courts follow the Federal Rules of Evidence (FRE), while state courts follow either their own rules of evidence or rely on precedent.² 

The FRE mandates that medical records—in addition to being relevant—must be³:

• Authenticated
• Compliant, with exceptions to hearsay and business records standards
• Made available to the opposition with adequate time for inspection
• Obtained legally

The Impact of Medical Records on Case Outcomes

Medical records can be the cornerstone of a trial strategy. They offer factual evidence, document a series of actions and decisions, and illustrate degrees of pain and suffering.

Using Medical Records to Support Personal Injury Claims

A personal injury case relies on medical records to help prove causality and calculate damages. They can:

• Provide proof of medical care sought immediately following an incident
• Detail the degree, duration, and pain level of an injury
• Show how an injury impacted physical functionality 
• Connect injury to work leaves and capacity
• Calculate the cost of medical treatment to date and potential future treatments

Medical Records in Medical Malpractice Cases

Medical malpractice lawsuits can make record acquisition and use particularly challenging, especially if poor or fraudulent recordkeeping is among the claims. Common malpractice matters and how they primarily use records include: 

• Misdiagnosis and failure to treat – Records can show a record of reported symptoms, medical history, and the presence or absence of diagnostic testing, referrals, and patient notifications.

• Surgical errors – Records should clarify whether the surgical actions matched the correct body part, who attended and what actions they took, tools and equipment used (and if any were left in the patient), complications that occurred during the surgery, follow-up directions, and symptoms reported following surgery.

• Medication and anesthesia errors – Records show what was prescribed, whether its selection or dosage ignored significant contraindications or comorbidities, whether it was dispensed properly, and what symptoms or complications subsequently arose, along with how they were or were not addressed.

• Birth injuries – Records show if errors were made in prenatal care, what techniques and tools were used, timelines and symptoms, and if brain or other injuries occurred during the birthing process.

Medical malpractice suits need to prove four elements through a combination of medical records and witness evidence⁴:

• The provider owed a professional duty to the patient
• The provider breached such duty
• The breach caused injury
• The injury resulted in economic and/or noneconomic damages

How Medical Records Can Influence Verdicts

In their original formats, medical records generally offer dry and confusing reading. In the hands of experts, however, they can be transformed into strategic exhibits and arguments that: 

• Provide the basis for narrative timelines
• Illustrate logical and scientific cause-and-effect connections
• Prove legal claims of actions and inaction
• Impeach witnesses who testify contrary to the medical record
• Demonstrate severity of damages, including with x-rays and other images 

Challenges and Risks in Using Medical Records as Evidence

Preparing effective medical evidence isn’t a simple task. Having it rejected based on a technicality, misunderstood by jurors, or simply not being able to locate or interpret what you hoped to find are all among the risks and challenges facing medical records management. 

Common Issues with Privacy and Confidentiality

While HIPAA applies to all medical records, there are additional federal or state regulations applicable—some of which include more restrictive rules, such as 42 CFR part 2 (Confidentiality of Substance Use Disorder Patient Records).⁵

When multiple sets of regulations apply to medical records, attorneys must apply the strictest version of each overlapping rule.

Authenticity and Accuracy Concerns

While some types of trial evidence must be an original object or document, medical records are typically authenticated copies. Accuracy is often presumed by virtue of the documentation procedures and digital file protections in place at the organization producing the electronic medical record. 

To avoid disputes with authenticity and accuracy, follow jurisdictional guidelines on: 

• Custodial, third-party, or other authentication in writing or through testimony
• Providing adequate time for the opponent to review and challenge the records
• Annotating, excerpting, or otherwise altering records for trial presentation

During  medical record review, look out for relevant information that may need to be investigated or clarified for accuracy, such as: 

• The inclusion of transferred records from prior healthcare providers 
• Errors due to autocorrect, mistranslation, form auto-fills, or other sources
• The use of unfamiliar or nonstandard abbreviations, acronyms, or terms
• Dates that suggest content was not written or submitted timely to an event or visit

Best Practices for Presenting Medical Records in Court

Winning a case that relies on medical records requires ensuring they’re accepted into evidence and that jurors can follow and believe your conclusions. 

Work with Experts to Interpret Medical Records

From figuring out what’s relevant to clarifying how to narrate and highlight key data, organizing and using different types of medical records in court proceedings is a specialized and highly regulated process. 

Attorneys can improve outcomes by partnering with medical records professionals who specialize in: 

• Retrieval across entities, such as health care, employment, human resources, insurance
• Annotating, tagging, and summarizing records
• Building timelines and narratives
• Interpreting medical, insurance, and other technical language and issues for legal use
• Identifying connections, inconsistencies, and red flags
• Navigating HIPAA and other applicable privacy regulations

Prepare Medical Records for Court Submissions

After retrieving the relevant medical records, attorneys need to prepare them as official evidence plus convert key medical information into presentations that jury members can understand and retain. 

Steps may include: 

• Maintain the authenticated copies in their original record format.
• Utilize a master key of all files to track requests, files, review status, and usage.
• Enter copies into a digital system that allows for bookmarking and annotating content.
• Standardize digital naming formats.
• Synch files across formats (e.g., doctors’ notes to images or audio files to transcripts).
• Represent key patient information by excerpting text or cropping images into trial presentations.
• Follow court guidelines on evidence labeling and case preparation.

Work with U.S. Legal Support Medical Record Retrieval and Management 

Since 1996, U.S. Legal Support has provided best-in-class litigation support services, including medical records retrieval and management to attorneys across practice areas throughout the country. In addition to medical record retrieval, we can provide record organization, summary, and analysis. Our processes are fully compliant with HIPAA, SOC 2 Type 2, and the NIST Cybersecurity Framework, with files delivered securely via a Client Portal using end-to-end encryption.

We also offer court reporting, transcription, interpreting, litigation consulting, and trial services including medical and other trial graphics and demonstratives, voir dire and jury research and consulting, mock trials, witness preparation, and trial presentation and technology services. 

Ready to learn more? Reach out today to connect with us on your medical records and other legal support needs.

Sources: 

1. HIPAA Journal. What Happens if You Break HIPAA Rules? https://www.hipaajournal.com/what-happens-if-you-break-hipaa-rules/
2. WomensLaw.org. Court System Basics: Rules of Evidence. https://www.womenslaw.org/preparing-for-court/court-system-basics/rules-evidence
3. ScienceDirect. Federal Rules of Evidence. https://www.sciencedirect.com/topics/computer-science/federal-rules-of-evidence
4. PubMed Central. An Introduction to Medical Malpractice in the United States. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2628513/
5. Holland & Hart. Medical Records: Definitions and Disclosures. https://www.hollandhart.com/files/77500_medical-records-definition-and-disclosures.pdf

Julie Feller

Julie Feller is the Vice President of Marketing at U.S. Legal Support where she leads innovative marketing initiatives. With a proven track record in the legal industry, Juie previously served at Abacus Data Systems (now Caret Legal) where she played a pivotal role in providing cutting-edge technology platforms and services to legal professionals nationwide.