Medical Civil Liability

Record-keeping

Under review

One cannot overemphasize the importance of creating good medical records in private practice and of entering all of the required notes in records in institutions. Not only are these records essential to care, but they are the best means of establishing the facts in cases of litigation. In a very recent judgment of the Court of Appeal, one reads:

“I am in agreement with the solicitor for the  appellant when he pleads that we must rely primarily on the notes in the medical record and, excepting clear and plausible explanations, we must consider that what was not noted, was not in principle done.” (Free translation). Marie-Josée Bérubé c. Hôpital Hôtel-Dieu de Lévis, 200-09-003122-006.

It should also be specified that, in cases of lawsuit, a physician must immediately seek help from the insurer. In fact, it is the insurer’s responsibility to defend the physician and to compensate the victim, if it is demonstrated that the physician committed a professional fault. The physician should never try to settle the dispute himself or herself and run the risk of adversely affecting the case and subsequently being refused coverage.

2011-04-04