Public Health Law Map - Beta 5 - Medical and Public Health Law Site

accepted as evidence, the person making that statement cannot be cross-examined
about the truthfulness of it. The court demands that the person who actually made the
statement be brought into the courtroom, placed under oath, and asked to repeat the
statement.
If this rule were applied to the medical record, everyone who made an entry in the
record would have to be called into the courtroom and asked which entries they
made, why they made them, and what information they based these entries upon—an
extremely time-consuming process and maybe even impossible. Because of these
practical difficulties, the courts have created the business records exception to the
hearsay rule: documents may be admitted into evidence without the requirement that
the persons who made the entries be available for cross- examination.
5. Business Records Exception to Hearsay
Documents are subject to cross-examination under the hearsay rule. Most documents
are hearsay because they record what others did and said, and are generally
maintained by someone who was not involved in matters in the records. There is an
exception to the hearsay rules for business records. For medical care practitioners,
the medical record is the key business record. Medical recordkeeping procedures
must fulfill the legal requirements of the business records exception if a medical
record is to be admissible in court. This exception to the hearsay rule requires that
the record meet four basic tests:
1. The record was made in the regular course of the business.
2. The entry in the record was made by an employee or representative of that
business who had personal knowledge of the act, event, or condition that is being
recorded in the record.
3. The record was made at or near the time that the recorded act, event, or condition
occurred, or reasonably soon thereafter.
4. The records were kept in a consistent manner, according to a set procedure.
a) Entry in the Regular Course of Business
The first requirement is that the entry be made in the regular course of business. For
a physician, the regular course of business is providing medical care, keeping
medical records, and complying with state and federal health laws. The medical
record will be admissible to prove the truth of activities related to the practice of
medicine. Entries in the medical record that do not deal with the practice of
medicine will not be considered to have been made in the regular course of
business.
For example, if a patient seeks medical care after being involved in an automobile
accident, the patient’s physical condition, as described in the medical records, will
be admissible as evidence in a legal proceeding. However, if the physician also
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