Medical Record

Without burdening doctors, hospital administrators, or record room supervisors by their having to attend court every time a medical record is needed in evidence, the rules say that evidence contained in medical or hospital records may be admitted at trial, provided counsel attests to having followed a simple but thorough authentication process. Here’s how it works. First the hospital responds to the attorney’s request for the records by providing them along with an affidavit certifying that the requested record is a true, complete, and accurate copy of the medical record requested. Then the lawyer who wants to offer the records in evidence makes the record available to opposing counsel by certified mail return receipt requested at least ten days before its planned use. Lastly counsel forwards to the court his pledge, under the pains and penalties of perjury, that the records provided to opposing counsel satisfy the statutory time and accuracy requirements. And, indeed, if these requirements have been met, the court permits the hospital records to be used at trial, as if authenticated by the doctor or hospital itself. The law can be so simple.

Here’s how it’s not supposed to work. Your long term paralegal, who you love in an appreciative platonic way, who knows your practice inside and out, who speaks Spanish and Russian and knows where all your files are, and who remembers things your cluttered mind forgets, neglects to send for the certified record for the case coming up for trial on Monday. It’s an effort she doesn’t want to undertake and, besides, her amateur paralegal mind trusts, or wrongly intuits production of these records will not ultimately be necessary; that this case will settle like all the others … she thinks. And then it is too late; and the boss wants to know if all the records which we have previously received from the hospital have been subsequently properly certified and served on opposing counsel, because today is the cut off day. And the paralegal says, “Yes.” And the boss says, “Show me.” And the paralegal takes another certification page, executed for another record received previously from the same hospital, and whites out the name of that client and substitutes the name of this client and sends the records off as certified and accurate under the pains and penalties of perjury. It is almost totally harmless, the records are accurate, the fabrication almost totally undiscoverable, no one will ever notice, and it’s only a teeny bit fraudulent.

But! If this is discovered as a fraud on the court, the boss will have to spend hours and hours denying he knew anything about it and righteously throwing his paralegal under the bus, all the while risking the loss of his license. Not worth it.

So he tells opposing counsel everything.
And he fires his paralegal.
Instantly.