In Gilbert v. Highland Hospital, Case No. 2015/03896, 2016 NY Slip Op 26147 (Supreme Court of New York, Monroe County, Mar. 24, 2016), a medical malpractice case, Plaintiff sued Defendant hospital on behalf of Plaintiff’s decedent, who presented at the hospital with nausea, abdominal pain and vomiting and was released several hours later without being seen by a doctor. Plaintiff’s decedent collapsed and died the following day. Plaintiff’s complaint alleges that Defendant was negligent in its failure to have procedures in place requiring a patient like the decedent to be seen by a doctor before being discharged.
Plaintiff sought production of the audit trail for decedent’s medical records to determine whether a doctor reviewed decedent’s records before she was discharged. Defendant objected, asserting that audit trails were not relevant, material or necessary and that the request was a “fishing expedition”. Defendant further argued that Plaintiff was not entitled to the audit trails because she had not disputed the produced hospital records’ authenticity. Plaintiff filed a Motion to Compel.
The court found that the audit trails were directly relevant to whether the decedent was seen by a doctor. The court reasoned that the audit trails were material and necessary because even though they do not describe what a doctor did, they do show if a doctor reviewed the records, which information could be explored further at deposition. Based upon this reasoning, the court disagreed with the Defense’s contention that the request was a fishing expedition. The court also determined that New York law did not require that Plaintiff dispute the authenticity of the hospital records in order to receive production of the audit trails. It was sufficient that Plaintiff sought the audit trails to establish a significant premise of the case, as to who viewed the decedent’s hospital records prior to her discharge. The court granted the Motion.
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