The medical record is the primary evidentiary foundation of nearly every medical malpractice trial. It is the contemporaneous account of what care was delivered, when it was delivered, who delivered it, and what the patient’s condition was at each documented point in the treatment timeline. In Georgia malpractice litigation, medical records must be properly authenticated before they are admitted into evidence, and once admitted, their content, including their gaps, becomes a focal point of the factual dispute. Expert testimony strategy and the standard of care itself are distinct subjects addressed elsewhere.
Authentication Requirements
Before medical records may be admitted as evidence in a Georgia trial, they must be authenticated, meaning the party offering the records must establish that the records are what they purport to be: genuine, unaltered documents created in the ordinary course of the patient’s medical care.
Authentication of medical records typically proceeds through one of several established evidentiary pathways. A custodian of records, usually a hospital records management employee or a practice administrator, may testify that the records were maintained in the ordinary course of business, that they were created at or near the time of the events they describe, and that they were made by or from information transmitted by a person with knowledge of those events. This foundation satisfies the requirements for admission as a business record, a well-established exception to the hearsay rule.
In many cases, authentication is handled through a records custodian’s affidavit rather than live testimony, where Georgia procedural rules permit this approach. The affidavit attests to the same foundational elements: the records were kept in the regular course of business, entries were made at or near the time of the events, and the records were maintained through established institutional processes.
The authentication inquiry can become contested when there are questions about the integrity of the records themselves. If a party alleges that records have been altered, backdated, or selectively produced, the authentication process transforms from a routine foundation into a substantive evidentiary dispute. In those circumstances, the party challenging the records’ integrity may present evidence of irregularities, inconsistencies, or metadata anomalies that call into question whether the records faithfully represent what occurred during the patient’s care.
Charting Gaps and Their Evidentiary Significance
What is absent from the medical record can be as significant as what is present. A gap in the charting, meaning a period during which no entries appear despite the patient being under active care, creates an evidentiary void that both parties will attempt to interpret in their favor.
The plaintiff’s use of charting gaps rests on a longstanding evidentiary principle: an event that is not documented is presumed not to have occurred. When a provider claims to have performed an assessment, administered a medication, or communicated with a colleague, but no corresponding entry appears in the medical record, the factfinder may infer that the event did not happen. This inference is not conclusive, but it shifts the burden to the provider to explain the absence of documentation through testimony or other evidence.
The defense may respond by offering testimony that the event occurred but was not recorded, citing the realities of clinical practice in which providers sometimes perform assessments or interventions without creating a contemporaneous record. The defense may also argue that the charting gap reflects a stable patient condition that did not generate documentation-worthy events, rather than an absence of monitoring or care.
The evidentiary weight of a charting gap depends on its context. A gap during a period when the patient’s condition was stable and the care plan called for periodic rather than continuous monitoring carries different implications than a gap during a period of documented clinical instability or immediately after a critical intervention. The timing, duration, and clinical context of the gap determine how powerfully the absence of documentation supports the inference that care was not provided.
EMR Metadata Role
The transition from paper-based medical records to electronic medical record (EMR) systems has introduced a category of evidence that did not exist in the paper era: metadata. EMR metadata includes information about when entries were created, when they were modified, who accessed the record, what changes were made, and the timestamps associated with each interaction with the system.
Metadata can serve as either a corroborative or an impeaching source of evidence. When the metadata timestamps are consistent with the clinical narrative presented at trial, they reinforce the reliability of the record. When they are inconsistent, they create powerful lines of inquiry. An entry that purports to describe an assessment performed at a particular time, but whose metadata reveals it was created hours or days later, may suggest that the entry is a retrospective reconstruction rather than a contemporaneous record. A record that shows multiple modifications during a period after litigation was anticipated may raise questions about whether the changes represent legitimate clarifications or self-serving alterations.
The availability and discoverability of EMR metadata vary depending on the system in use and the institution’s data retention practices. Not all EMR platforms expose the same level of audit trail information, and the technical process of extracting metadata may require specialized knowledge. The evidentiary significance of metadata is well recognized, but the practical ability to access and interpret it depends on the specific system and the parties’ diligence in preserving and requesting this information during the discovery process.
Consider a scenario where a patient’s medical record contains no entries for a defined period during an overnight hospital stay. The patient’s condition deteriorated during that interval, and by the time the next entry appears, the patient’s status has changed significantly. The charting gap covers the precise period during which the clinical deterioration occurred. The plaintiff would point to the absence of documentation as evidence that no assessments were performed during the critical period. The defense would need to explain the gap, either by producing testimony that assessments occurred but were not charted, or by presenting EMR metadata showing that the record was accessed during the interval even though no entries were created.
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Disclaimer
This content is produced exclusively for general informational and educational purposes. It does not constitute legal advice, does not create an attorney-client relationship, and should not be relied upon as a substitute for professional legal counsel tailored to specific facts and circumstances.
No reader should act or refrain from acting on the basis of this content without first seeking qualified legal advice from a licensed attorney admitted to practice in the relevant jurisdiction. Medical malpractice law involves complex, fact-intensive analysis that varies significantly depending on the specific clinical context, the parties involved, the applicable procedural rules, and the current state of statutory and case law at the time of the claim.
The statutes, rules, judicial holdings, and legal principles referenced in this content reflect the law as understood at the time of writing. Georgia law is subject to legislative amendment, judicial reinterpretation, and regulatory change at any time. Specific provisions discussed herein, including but not limited to damage cap rulings, tort reform legislation, statutes of limitation and repose, expert qualification standards, and procedural filing requirements, may have been modified, superseded, or reinterpreted after the date of publication. Readers must independently verify the current status of all legal authorities cited before relying on any information contained in this content.
This content does not cover every aspect of Georgia medical malpractice law. Certain topics have been intentionally excluded from the scope of this publication, and the inclusion or omission of any particular subject should not be interpreted as a statement about its legal significance or relevance to any specific case.
The examples and scenarios presented throughout this content are hypothetical illustrations designed to clarify legal concepts. They do not represent actual cases, real parties, or guaranteed legal outcomes. The outcome of any medical malpractice claim depends on the unique facts of that case and the professional judgment of the attorneys and experts involved.
Nothing in this content should be construed as an opinion regarding the merits of any potential or pending claim, as a prediction of any legal outcome, or as an endorsement of any particular litigation strategy.