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Offering Evidence within Medical Records

Offering Evidence within Medical Records

To best explain the issues of offering medical records in a trial, a fictional situation is implemented. I have set up a hypothetical fact scenario in which the plaintiff must oppose a fictional defendant’s objections to plaintiff’s attempt to offer medical records into evidence.

The hypothetical facts follow. As a result of an accident, the plaintiff sustained serious and severe personal injuries and damages. At a deposition for purposes of trial, the plaintiff moved her medical records into evidence. The parties had agreed prior to the deposition that the medical records were authentic. However, the defendant objected to the records at the deposition. After the deposition, the defendant filed a motion to exclude plaintiff’s medical records from evidence at trial. The defendant argued the plaintiff did not lay a foundation or authenticate the records. The plaintiff’s response to the objection follows.

Defendant’s argument is improper and unsubstantiated.  Both parties agreed the records were authenticated through correspondence and the records were further authenticated by expert testimony in this matter.  Defendant, in response, argues the medical evidence is inadmissible because it is hearsay and were not properly authenticated.

1. The medical records were authenticated

The requirement of authentication or identification as a condition precedent to admissibility is satisfied by evidence sufficient to support a finding that the matter in question is what its proponent claims.  Pa.R.E. 901.  This includes testimony by a witness with personal knowledge, which may be sufficient to authenticate or identify the evidence. Commonwealth v. Hudson, 414 A.2d 1381 (Pa. 1980) citing Pa.R.E. 901(b)(1).  The authentication requirement can also be waived by stipulation or by failure to object in a timely manner.  See Pa.R.Civ.P § 4014.

The plaintiff wrote to the defendant to confirm an agreement made by counsel before the deposition. The parties discussed various issues in order to make the pending trial less burdensome. Plaintiff faxed a follow-up letter to Defendant. The relevant issues discussed included,

1) That it was not necessary “for either party to call as a witness the record custodians or other medical representatives, in order to establish the authenticity of the medical treatment records and bills for purposes of admitting the same into evidence,” and reserving any substantive objections with the purpose of the agreement to avoid the need for authentication.  (Exhibit A at p. 1 #1).

Defendant answered the plaintiff and its letter contained the following relevant confirmation: “In relation to point 1, we agree with the stipulation as stated.”  Based upon the aforementioned agreement between parties, defendant’s argument is unpersuasive.  The stipulation process provides parties with the opportunity to identify and resolve authentication issues before trial, and, as a result, avoid surprises at trial, including the preclusion of evidence on the grounds of lack of authentication as defendant now seeks.  Clearly, the necessary steps were taken to facilitate an agreement between parties as to authentication and any argument to the contrary is disingenuous. Under such a fact situation, the court would hold the medical records were authentic. Again, the authentication requirement can be waived by stipulation or by failure to object in a timely manner.  See Pa.R.Civ.P § 4014

2. The medical records are not excluded by the hearsay rule

The defendants then argued that even if the medical records were authenticated, the records are hearsay and, thus, not admissible. Hearsay is defined as “a statement, other than one made by the declarant while testifying at trial or hearing, offered in evidence to prove the truth of the matter asserted.”  Pa. R. Evid. 801. 

Nevertheless, there are, as defendant has failed to include, exceptions to the hearsay rule.  Physicians relied upon the reports, exhibits, deposition transcripts and testimony by physicians entered into the record in this matter.  According to Rule 803 (6) of the PA Rules of Evidence, evidence is not excluded by the hearsay rule if it is a record of regularly conducted business activity.  That is, evidence is not excluded by the hearsay rule if it is . . .

“a memorandum, report, record, or data compilation, in any form, of acts, events, or conditions, made at or near the time by, or from information transmitted by, a person with knowledge, if kept in the course of a regularly conducted business activity, and if it was the regular practice of that business activity to make the memorandum, report, record, or data compilation, all as shown by the testimony of the custodian or other qualified witness . . .” Pa.R.E. 803 (6).

The records relied upon are records that have been entered into evidence and are records of regularly conducted business activity. 

Furthermore, Rule 803 (4) of the Pennsylvania Rules of Evidence provides a statement is not hearsay if it is . . .

“A statement made for purposes of medical treatment, or medical diagnosis in contemplation of treatment, and describing medical history, or  past or present symptoms, pain or sensations, or the inception or general character of cause or external source thereof, insofar as reasonably pertinent to treatment, or diagnosis in contemplation of treatment.”

Pursuant to the exceptions, case law supports medical records are not excluded by the hearsay rule as they reflect statements made for the purposes of medical treatment and/or the other provisions set forth in this hearsay exception. Further, hospital records are admissible under the business records for the purpose of demonstrating such evidence: hospitalization, treatment and symptoms. Sprague v Walter, 656 A.2d 890, 911-912 (Pa. Super. 1995).

In Sprague, treatment records of the Plaintiff were admitted over the objection of hearsay by the Defendant. On appeal the Superior court confirmed it was not an error to admit the treatment records under the business records exception to hearsay, because although opinions and diagnosis are generally excluded from the hearsay exception of a business record exception, under the business exception the records are still admissible to show the hospitalization, treatment and symptoms found. Id. at 911-912.

CONCLUSION

Under the fictional fact scenario, the medical records would have been admitted for the reasons identified herein.

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