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- Chapter Seventeen Medical and Hospital Record Evidence
17.0 I. Admissibility Under The Business Records Rule
Jurisdiction | New York |
I. ADMISSIBILITY UNDER THE Business Records Rule
Any writing or record made as a memorandum or record of any act, transaction, occurrence or event is admissible in evidence as proof of that act, transaction, occurrence or event, provided the judge finds the document was made in the regular course of any business and it was the regular course of the business to make it.383 The term business includes a business, profession, occupation and calling of every kind.384
Records and writings are not only admissible under the business records rule but are also prima facie evidence of the facts contained therein.385 A statement in a record or report may be admitted as proof of the facts recorded therein if the informant was under a business duty to perceive the event and to transmit information concerning the event to an individual who was under a business duty to record it. The fact that an entry is self-serving does not bar its admission.386
If the informant was not under a business duty to impart the information but the individual who entered the information was under a business duty to obtain and record the statement, the entry is admissible merely to establish that the statement was made. A hearsay exception is needed in order to admit the statement for its truth.387
A business record is admissible even if the person who prepared the record is available to testify.388 Voluntary hearsay statements by third persons not employed by the hospital or under any duty in relation to the hospital or its business are not admissible under CPLR 4518.389 An entry is inadmissible absent proof as to (1) who made the entry, (2) whether such individual was under a duty to make the entry, (3) the source of the information or (4) whether the entry was made in the regular course of business.390
The judge also must find, as a condition for admission into evidence, that the entry was made at the time of the act, transaction, occurrence or event or within a reasonable time thereafter.391 A business record made within a reasonable time of the related occurrence is admissible as a business record under CPLR 4518;392 a record or report not made within a reasonable time after the related event is not admissible under the business entry rule.393
All other circumstances surrounding the making of the document, including the maker’s lack of personal knowledge about the event, may be shown to the jury to affect the weight of the document but not its admissibility.394 Objections that go to the weight of a diagnosis or treatment noted in a record do not affect the admissibility of the record.395 A challenge may be made, however, based upon the argument that no foundation was laid as to either the nature of the tests and procedures recorded or the scientific reliability of such tests and procedures.396
Objecting to admission of a hospital or medical record under the business records rule preserves a party’s right to seek appellate review of a subsequent erroneous receipt of the record when offered under a different evidentiary rule.397 A party waives his or her right to...
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- Chapter Seventeen Medical and Hospital Record Evidence
- 16.1 II. Fall Prevention
- 16.2 III. Pressure Ulcers
- 16.3 IV. Dehydration
- 16.4 V. Resident Mobility And Treatment
- 16.5 VI. Infections
- 16.6 VII. Nutrition
- 16.7 VII. Choking
- 16.8 IX. Respiratory Therapy
- 16.9 X. Sexual Assault
- 16.10 XI. Doctor Liability Under The Public Health Law
- 16.11 XII. Accuracy Of Records
- 16.12 XIII. Discovery
- 16.13 XIV. Burden Of Proof
- 16.14 XV. Damages
- 16.15 XvI. Conclusion
- 17.0 I. Admissibility Under The Business Records Rule
- 17.1 A. Hospital Records
- 17.2 B. Medical Office Records
- 17.3 C. Inadmissible Records
- 17.4 D. Electronic Records
- 17.5 E. Medical Records In Criminal Proceedings
- 17.6 II. Laying A Foundation
- 17.7 A. Who Can Authenticate Medical Records?
- 17.8 B. Certification
- 17.9 1. Hospital Records
- 17.11 3. Records Produced Pursuant To Subpoena Duces Tecum
- 17.12 A. Contents Of Certification
- 17.13 B. Notice Of And Objection To Authentication By Certification
- 17.14 C. Certification Of Out-Of-State Office Records
- 17.15 III. Admissibility Of Specific Entries In Hospital And Medical Records And Related Testimony
- 17.16 A. Alcohol And Drug Abuse Entries
- 17.17 B. Entries Regarding Manner Or Cause Of Accident
- 17.19 D. Prior Inconsistent Statements
- 17.20 E. Prior Consistent Statements
- 17.21 F. Party Admissions
- 17.22 G. Statements Relevant To Material Element Of Claim
- 17.23 H. Opinions Expressed In Medical Records
- 17.24 I. Reports, Letters And Other Documents In Medical Record
- 17.25 1. Medical Reports
- 17.26 2. Letters
- 17.27 J. Records And Reports Prepared For Litigation
- 17.28 K. Radiogram Evidence
- 17.29 1. X-Rays And The Best Evidence Rule
- 17.30 2. Authentication Of X-Rays
- 17.31 L. Incident And Accident Reports
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