One of the most important of many areas of discovery in a medical malpractice case is the examination before trial of the defendant doctor. As part of that discovery process is to make sure you obtain a complete certified copy of the doctor’s office records, if any, well before the deposition takes place. In addition you want to make sure that the defendant brings with them their original office chart, not just a certified copy. You want to have the opportunity to examine that original chart for a number of very important reasons. First a review may help support any claims that the doctor may have added or changed his original records to help support his version of facts concerning treatment, conversations, etc. By having an opportunity to review the original chart you can determine, if it contains handwritten notations, whether the doctor used different color pens to generate the same contemporaneous note, especially if the suspected addition which supports his version of events is in a different color ink.
Phil Papa of our office, once had a case against a defendant podiatrist who was being sued for failing, at an office visit, to recommend emergency hospitalization to my client, a diabetic, for treatment of an infected diabetic foot ulcer. His office notes stated that he advised the patient to immediately proceed to the nearest emergency room for treatment. My client testified that he was never told to seek hospitalization. He ended up with a partial amputation of his foot. I requested a discovery and inspection of the original chart because the doctor had not produced it at his deposition. During a careful examination of the office notes which were handwritten on note paper. I picked up that the watermark on the note paper he generated the note in question established that the piece of paper was printed a year after the date of the visit in question. He obviously had decided to rewrite that note with changes but didn’t realize that the paper he used was manufactured after the fact! Needless to say the case immediately settled.
While many firms suggest that they specialize in handling medical malpractice cases, it is imperative that a client or the family of a loved one, consult and retain an firm that has the background and experience in handling the nuances that come with medical malpractice. At Leav & Steinberg, LLP your case will be reviewed and if handled, no aspect of the case will be ignored.