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How do you lay a foundation to get medical records into evidence?

 

A: “I offer this report into evidence,” the attorney says.
“Objection,” yells the defense attorney. “No foundation.”
“Sustained,” commands the judge.

What just happened?

The lawyer tried to get a report into evidence so the jury can see it. The problem was that he did not establish where the report came from, whether it was certified to be true and accurate and whether it was made in the ordinary course of business.

Why is that important?

The justice system says that you can show or read a report into evidence. However, before doing so, you need to establish that this was made in the regular course of business. For example, if the attorney was trying to get into evidence the patient’s medical records, he would need to show that those records were made by the doctor at every visit. He would then need to show that those records were kept according to protocol and procedure and stored in a file cabinet along with all patient records.

Someone from the office would need to come into court to say that they are original records (or certified copies) and they are maintained like all patient records in their office.

Since this function is routine, the courts have allowed attorneys the opportunity to avoid having to call into court a witness from the doctor’s office who can attest to how these records are made, kept and stored.

This is typically done by serving a subpoena on the doctor’s office and providing a form for the office to fill out. This will confirm and certify that they are accurate records and are maintained in the ordinary course of business.

Assuming that all parties agree to admit the records in this fashion, there should be no objection by the defense. If they do object, then the attorney will simply call a record-keeping witness to the stand and ask a series of basic questions to establish the chain of custody and that the records are accurate and made in accordance with office procedure.