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

entered the patient’s description of the accident into the medical record, this would
not be admissible because investigating accidents is not part of the regular course
of business for a physician. Thus, the information about the accident would be
excluded from the courtroom as hearsay.
In general, physicians should refrain from making entries into the medical record
that are not directly concerned with the provision of medical care or with legal
matters that are necessary to the rendering of medical care (for example,
guardianship status or court orders bearing on the rendering of medical care).
b) Personal Knowledge
The requirement that the entry be made by someone who has personal knowledge
of the event being recorded or that the information be transmitted directly to the
person making the entry from someone who has personal knowledge allows a
physician to dictate notes to be transcribed and put in the chart. The transcriptionist
need not have any personal knowledge of the medical care rendered because he or
she is getting the information from someone who is familiar with the care given.
The requirement of personal knowledge is a problem in teaching institutions. In
some cases, a physician may write chart notes and summaries for a patient he or
she has not personally cared for or discussed with the physician who did care for the
patient. If the recording physician does nothing more than summarize data already
in the medical record, there will be no problem with the personal knowledge
requirement, because the physician, by reviewing the record, will have personal
knowledge of the data in the record.
Problems arise when the physician draws conclusions about the patient’s condition
based on data in the record. Although these conclusions are incorporated in the
medical record, they are not based on personal knowledge of the patient’s
condition. This failure of personal knowledge could be legal grounds for attacking
the admissibility of the conclusions in court.
c) Timely Entry in the Usual Course of Business
The requirement of the law that is most frequently not complied with is that the
entry be made at or near the time of the act, event, or condition described. The
courts allow reasonable delay, given the circumstances of the business. Most
hospitals use the Joint Commission on Accreditation of Healthcare Organizations
30- day standard for completing the chart, with certain time- critical entries to be
completed in 72 hours. (This does not mean that entries can be backdated. Progress
notes and other daily memoranda must be made on the day to which they pertain.)
Although the courts would generally ignore this delay, it is certainly questionable
whether 30 days is a reasonable delay. Since both plaintiffs and defendants usually
want the record admitted to court, there has been little litigation on whether
medical records actually meet the requirements of the business records
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