The Role of Medical Records in Medical Malpractice Litigation 

Medical records, reports, lab results, and chart notes play a vital role in medical malpractice claims. They serve as the primary form of evidence in medical malpractice actions, demonstrating whether a medical professional fell below the standard of health care, and caused harm through negligence. Inaccurate, incomplete, contradictory, or vague chart notes can weaken a medical professional’s defence and bolster the argument that substandard medical care results in harm to the patient.

To be successful in an action for medical malpractice (also known as medical negligence), a plaintiff will have to prove the following three essential trial elements:

  1. A doctor, nurse, or other medical professional provided substandard medical care that did not meet the “standard of care” required of that professional;
  2. The patient who received substandard medical care suffered harm, injury, or damages; and
  3. The harm, injury, or damages was caused by the substandard medical care.

Medical malpractice lawsuits are dependent on the testimony of an expert witness, typically a doctor, nurse, or other medical professionals of the same specialty as the defendant. This expert reviews the evidence and provides a professional opinion on whether the plaintiff’s injuries were caused by a medical professional’s failure to meet the standard of care.

Medical records, chart notes, and reports are crucial evidence that forms the foundation for an expert witness’s opinion. Medical chart notes include important information such as patient vital signs, medication timing, healthcare provider interactions, and assessments of the patient’s condition. All of this information plays an important role in proving that the medical care a patient received fell below the standard of care and caused the patient’s injuries.

How do medical records prove a breach of the standard of care in medical malpractice?

The “standard of care” in medical malpractice cases has been defined by Canadian courts as “the standard of a reasonable doctor in the same circumstances.” This is an objective standard, not based on the individual doctor’s own skills or practices, but on what the law say a reasonable doctor in that situation would have done. In medical malpractice cases, the plaintiff must prove that a medical professional fell below the standard of care and provided services that were substandard compared to a reasonably competent and prudent medical professional in the same circumstances.

Canadian courts recognize that judges are not medical professionals and do not have the specialized technical knowledge necessary to fully comprehend the complex scientific issues involved in medical malpractice actions. It is an expert witness’s job to help the court understand how the standard of care should be defined, and then to explain how that standard of care was breached.

The expert witness will compare the information provided in the plaintiff’s medical charts and records to the clinical practice guidelines and established standard practices that medical professionals and hospitals are required to follow. If the medical records and chart notes reveal a deviation from the accepted practice guidelines, this can be evidence in superior court that a medical professional fell below the standard of care.

How do medical records prove a patient suffered damages due to medical negligence?

In medical malpractice actions, there is often an obligation for a plaintiff to provide ongoing disclosure of medical records beyond those directly related to the incident in question. Records, reports, and chart notes relating to ongoing treatment following an incident are also disclosed. These additional records can play a crucial role in substantiating claims of damage and harm, providing a comprehensive view of the impact and consequences of medical errors. Medical records can reveal instances of medical error where healthcare professionals’ neglect or substandard care led to harm, injury, or death, underscoring the importance of thorough documentation and review.

A plaintiff can also use treatment notes from a family doctor, lab tests, prescription records from a pharmacy, or records from a physiotherapist/occupational therapist regarding the injury suffered as evidence of the severity of their injury, and the degree to which their life is impacted by that injury. These documents are pivotal in demonstrating the serious consequences of medical mistakes, including the emotional and financial impact on patients and their families, and the necessity for detailed investigations to uncover instances of medical malpractice.

How do medical records prove the causation of the injury?

If you have experienced medical negligence and suffer from ongoing injuries, it may feel obvious that the medical negligence caused your injuries. However, simply proving a breach of the standard of care is not enough in the complex field of medical malpractice law. Success in a medical malpractice action is dependent on proving that the medical negligence caused the plaintiff’s injuries. This process, involving the legal complexities and technicalities of proving causation, is often the most challenging aspect of a medical malpractice claim case.

An expert witness will review the plaintiff’s medical records, chart notes, and reports from physicians, and will provide a professional opinion on whether the evidence contained in the plaintiff’s medical records prove that the patient’s injuries were caused by the medical negligence at issue.

Given the challenges and complexities of medical negligence cases, it is crucial to seek expert legal guidance to navigate these intricate legal processes and to give a voice to those impacted by medical malpractice.

How do I request my medical records?

If you believe you have suffered injuries as a result of medical negligence, the experienced medical malpractice lawyers at BIMMA can help you every step of the way. As a patient, you may request a copy of your medical records from the hospital, doctor’s office, or any medical professional where you received medical care. Alternatively, the lawyers at BIMMA can make these requests on your behalf, with your consent. The experienced medical malpractice lawyers at BIMMA can then review your medical records and provide you with a no-obligation consultation to help you decide whether an action in medical malpractice is the best course for you.