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The Importance of Maintaining 'Chain of Custody' for Your Medical Records

In criminal law, the term 'chain of custody' is a familiar concept and until some years back it was not a major concern for civil litigators. But with the advent of online records, the actual nature of evidence in civil litigation has undergone a sea change. From tangible paper records to electronic data, the average New York lawyer now has to change his attitude towards records used as evidence in court. And that means being hyper aware of the chain of custody (COC) and how this can affect the outcome of the trial.

In a medical malpractice case, both the prosecution and the defense will ask for medical records of the patient from all the different hospitals where they have been treated. In addition, the defense may even request the patient's employer to send their copies of the patient's medical history over. Access to medical records is an important step in the discovery process. But the records are never sent directly to the lawyers who requested them. Instead, they are subpoenaed into the record room in the court where the trial will take place. Why is this done?

Proving accuracy of medical records is important in trial

Subpoenaing medical records is the first step in maintaining chain of custody. Since many hospitals keep medical records online, it is easier to alter the data electronically. Also, when a lawyer uses the patient's medical records in court there is no way of proving that the records are accurate.

If the prosecution and the defense have both asked for copies of the medical records separately, then there are chances of the records being altered and either side can claim that their version of the record is the actual truth. In order to avoid such confusion, the law makes it mandatory for record providers to send the copies to the court and not to the lawyers individually.

Ensure records are certified and unaltered

When the hospitals are subpoenaed, they have to send verified copies of the patient's records to the court. Each and every record has to be certified by the hospital's record keepers to the effect that they are admissible in court according to New York State rules. Attorneys can provide appropriate certification forms along with the subpoena to ensure that the resulting records are compliant with the statuary rules for the certification of admissibility of medical records.

Before the trial begins, i.e. during the discovery process, the attorneys can go to the court's subpoena record room and take out the relevant records and use them for research. Each time the records are taken out, it is important to maintain the chain of custody for future references.

Maintaining COC for medical records avoids instances in which medical evidence is refuted in court because it could not be proved to be authentic. As a precaution, attorneys should always insist on the hospital providing original records during deposition. Just like it is vital to maintain COC and preserve authenticity, it is also crucial that you compare your copy of the records with the original to rule out any misconduct.

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