What Can Your Clinical Records be Used for at Trial?

Whenever a physician or health-care practitioner meets with a patient they are obliged to keep records of that visit. These clinical records contain the patient’s subjective complaints along with a physician or health-care practitioner’s objective observations, assessments and the specifics of the treatment plan that is prescribed. Therefore, clinical records are often relevant in personal injury and insurance litigation cases and usually play an important role in the course of litigation.

At trial, clinical records are admitted as evidence under the “business records” exemption of the Evidence Act. However, the courts in British Columbia have held that clinical records may only be used for limited purposes.

Clinical records are admissible evidence for proof of fact. An example of this would be the fact that a patient visited the physician on the date indicated. Although, clinical records are admissible for the fact that they were made they are not admissible for their truth in the absence of any proper evidence to that effect. For example, a diagnosis which is recorded in a clinical record is admissible evidence to prove that the diagnosis was made but the court cannot accept the diagnosis as correct in the absence of proper opinion evidence to that effect.

Further, clinical records may also be used to challenge credibility. If you testify at trial and make a statement which is inconsistent with your recorded statement in a clinical record, then opposing counsel may cross-examine you on that inconsistency. This may be done in an attempt to discredit and challenge your credibility. In litigation, credibility is of the utmost importance and can influence the outcome of the trial.

Therefore, it is important to be thorough with your physician or health-care practitioner in order to ensure that your injuries are fully documented.

If you would like to learn about the disclosure of clinical records please review one of our previous articles, Disclosure of Your Clinical History, written by Perry Armitage, Partner.

If you have any questions about the use of clinical records at trial in a personal injury or insurance litigation matter, contact us today at 604-581-7001. We are here to serve you.