Medical Records Are Considered More Accurate Than Witness Testimony in Legal Proceedings
In an inquest, the medical record is generally considered the more trusted and accurate source of truth compared to witness testimony, including that of physicians. Courts have long held that an unaltered contemporaneous medical record carries greater evidentiary weight than human memory 1.
Legal Foundation for Medical Record Primacy
The legal system operates on a fundamental principle regarding documentation versus recollection:
Courts consider clinical documentation to be discoverable and treat the existence of an unaltered contemporaneous medical record as a more trusted source of truth than the memory of a physician or patient 1.
Medical records are increasingly viewed as legal documents, not merely clinical aids, and serve critical evidentiary functions in legal proceedings 2.
The documentation in medical records is considered to be legally and medically accurate and reliable by courts 3.
Role of Witnesses of Fact vs. Medical Records
When physicians testify as witnesses of fact (rather than expert witnesses), their role is distinctly limited:
A witness of fact has an ethical obligation to testify honestly and truthfully to the best of their medical knowledge, but they are not to be an advocate or partisan in the legal proceeding 1.
The treating physician testifying as a witness of fact is expected to be adequately prepared, but their testimony is still subject to the limitations of human memory 1.
Why Medical Records Take Precedence
Several factors explain the legal preference for medical records:
The contemporaneous nature of medical documentation - records created at the time of care are less subject to memory decay, bias, or post-hoc rationalization than testimony given months or years later 1.
Objective documentation - medical records provide a written trail that can be examined, cross-referenced, and verified, whereas witness testimony is inherently subjective 1.
Legal discoverability - the fact that medical records are discoverable has driven more extensive and defensive documentation practices, making them more comprehensive 1.
Important Caveats
Despite the primacy of medical records, several limitations exist:
Medical records may contain inaccuracies - studies have shown that only 59% of information present in patient-physician interactions appears in the medical record, with particular gaps in medical history documentation 4.
Record quality varies significantly - there is documented variability in the quality of medical records, and incomplete recording may not reflect the actual care provided 5, 4.
Tampering destroys credibility - if a physician is discovered to have altered medical records, this constitutes fraud upon the court and immediately undermines their entire case, regardless of the merits 2.
Practical Implications
In cases of discrepancy:
The jury or judge (trier of fact) ultimately determines the weight given to each piece of evidence, but they will typically favor the contemporaneous medical record over later testimony 1.
Witness testimony serves primarily to explain, contextualize, or interpret the medical record, not to contradict it 1.
Cross-examination and presentation of contrary evidence are the appropriate mechanisms to challenge questionable documentation, but the burden remains on challenging the written record 1.