A recent case from the Illinois Appellate Court, Troyan v. Reyes (3d Distr. 9/29/06), contains a helpful primer for getting medical records into evidence without a doctor to sponsor them. Though plaintiff's counsel wanted to introduce medical records at trial, the doctors were not available to testify. As a work-around, plaintiff's counsel called the record keepers from the various hospitals and had them testify to the foundational requirements for business records, which are found in Illinois Supreme Court Rule 236.
Any writing or record . . . made as a memorandum or record of any act, transaction, occurrence, or event, shall be admissible as evidence of the act, transaction, occurrence, or event, if made in the regular course of any business, and if it was the regular course of the business to make such a memorandum or record at the time of such an act, transaction, occurrence, or event or within a reasonable time thereafter . . .
At trial, the record keepers testified to these foundational requirements. During closing, plaintiff's counsel wanted to publish the records to the jury. When the defendant objected, the trial court denied the request as to a radiology report and some of the other medical records that contained "observations, assessments, diagnoses and impressions of certain doctors."
On appeal, the Troyan court considered whether the medical records, which contained the opinions and diagnoses of absent doctors, should have been published to the jury under the business-records exception to the hearsay rule.
After setting out the foundational requirements for business records from Rule 236, the court made the following points:
- First, in order to introduce a record under the business-records exception to the hearsay rule, "it is not necessary that the author or creator of the record testify or be cross-examined about the contents of the record";
- Second, once a witness has established the foundational requirements, "the records themselves should be introduced";
- Third, these rules apply even to "diagnoses and opinions contained in medical records," which should be "admissible and published to the jury as a proper part of the business records exception to the hearsay rule";
- Fourth, there is an important exception: when the medical records either aren't relevant or are "too complex for the jury to understand on its own," then these rules do not apply and the medical records should not be introduced into evidence.
Applying these principles, the Troyan court held that the radiology report, which contained "complicated medical terminology," was "too complex and confusing to aid the jury absent medical testimony." Most of the other medical records were admissible, however, since the jury "could have easily understood the opinions and diagnoses contained" in the reports in that they did not contain "difficult medical terminology or opinions."
Related post: "Police Accident Reports and the Business Records Rule."