Importanța înscrisurilor medicale în litigiile de malpraxis medical
The importance of medical records in medical malpractice litigation

Summary/Abstract: Medical information is manifested both at the level of substantive law and at the level of procedural law. In this study, the importance of medical information will be analysed from the perspective of substantive law. This is relevant for clarifying the medical situation. Determining the medical condition is the means by which one of the fundamental guarantees of the civil or criminal process is ensured – the right to a fair trial. The records, which materialize the content of medical facts, present a determining relevance in the civil or even criminal process. Depending on these, the conformity of the medical conduct, respectively the illegal act, will be determined. Likewise, they will serve to establish the physical or mental damage. More importantly, medical records are evidentiary elements, which gives them the nature of forensic documents. Thus, the medical or forensic expertise will be drawn up based on them. The expert will formulate the conclusions from the expert report, depending on the content of these documents and the medical facts revealed by them. Any deviation from their content will be thoroughly explained, to ensure the objectivity and impartiality of the expert report. Last but not least, medical records are of major relevance to determine the compliance of medical conduct with the standards of medical science, from the moment of providing the medical service, contained in the Guides, in the Protocols, in the specialised literature or in clinical studies.

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