Court of Appeals Restricts Use of Medical Narratives at Trial

The Court of Appeals last week restricted the use of medical narrative reports in injury cases, holding it was reversible error to admit a neurologist’s unedited notes from the patient’s medical visits. The notes did not comply with O.C.G.A. § 24-3-18’s requirements for medical narratives, because they contained unexplained medical terms and test results and were not organized or structured to make them more readily understandable to the jury.

This decision is both good and bad for injury victims.  The statute was passed to make it less expensive to introduce medical evidence at trial.  When medical reports are written in clear prose, narrative reports help establish the plaintiff’s case.  We generally use only the ones that are reasonably understandable reports to fill in gaps between medical depositions.  Some lawyers like to use them as the entire medical proof in a smaller case.  On the other hand, defense lawyers like to dig up old medical reports and introduce office notes as medical narratives. So this decision cuts both ways.

Frankly, if I have to pay a doctor to write a narrative, I’d just as soon pay a few hundred dollars more and take the doctor’s deposition on video for use at trial, with the doctor explaining everything with some visual aids.

Lott v. Ridley
Court of Appeals of Georgia
A07A0488 (civil case)
May 23, 2007
Ruffin, Judge.
07 FCDR 1617 (06/08/07)

Ruffin, Judge. Barbara and Clarence Ridley brought a personal injury action against Jesse Lott to recover for damages allegedly resulting from an automobile collision. After trial, a Glynn County jury awarded the Ridleys $16,398.68 for medical expenses and $38,000 in compensatory damages. Lott appeals the denial of his motion for a new trial, arguing that the trial court erred in admitting narrative medical testimony and allowing the jury to consider future medical expenses. Because we agree that the trial court erred in admitting certain medical testimony, we reverse. 1. Lott contends that the trial court should not have admitted reports from two of Barbara Ridley’s doctors because they did not comply with the medical narrative requirements set forth in OCGA § 24-3-18. Subject to certain requirements, OCGA 24-3-18 (a) provides an exception to the hearsay rule and authorizes the admission of written medical reports without requiring the doctor’s testimony at trial.1 The statute “applies to reports which set forth, in story form, the author’s assessment of the patient’s history, examination, diagnosis, treatment, prognosis, or interpretation of tests or examinations, including the basis therefor.”2 However, records which would require an expert to explain them are still subject to a hearsay objection, as “the law authorizes the admission of only those reports which, rather than consisting of unexplicated medical terms and uninterpreted scientific test results, set forth the relevant information in prose language that is more readily understandable to laymen.”3 We review a trial court’s decision on the admissibility of evidence under an abuse of discretion standard.4 Lott asserts that two of the doctors whose reports were tendered at trial made no attempt to use lay language or to explain any of the medical terms they used. Counsel for the Ridleys read into the record reports by three doctors, including Dr. Halverson, a chiropractor, and Dr. Shenkman, a neurologist. Dr. Halverson’s report is in a narrative form and summarizes Barbara Ridley’s injuries and treatment. It presents the relevant aspects of her injury, diagnosis, treatment, and prognosis in a logical form. While it contains medical terms, it attempts to explain those terms in the context of the report. Thus, based on our review of the record, the trial court did not abuse its discretion in admitting Dr. Halverson’s medical narrative into evidence.5 Dr. Shenkman, however, apparently did not provide a narrative report summarizing Barbara Ridley’s condition and treatment; rather, counsel simply read into the record the contemporaneous notes made by Dr. Shenkman at each of Barbara Ridley’s visits to him. These notes detail all of the treatments given to Barbara Ridley, and are replete with unexplained medical terms and test results.6 While many of the medical terms used are identical to those used by Dr. Halverson, the notes do not attempt to explain the terms or put them in context. At one point during the reading of the notes, counsel stated that the notes gave “a long string of numbers here that [I am] just going to skip and get down to the summary.” This bare recitation of the doctor’s unedited records clearly is not a medical narrative “in story form,” as contemplated by the statute, as it does not “set forth the relevant information in prose language that is more readily understandable to laymen.”7 No attempt at all was made to organize the doctor’s notes or structure them to make them more readily understandable to the jury. Accordingly, we find that the trial court abused its discretion in admitting Dr. Shenkman’s notes under OCGA § 24-3-18.8 The Ridleys argue that any error in admitting the medical narrative was harmless. The improper admission of evidence is harmless “when the erroneously admitted evidence is simply cumulative of admissible and admitted evidence” and there is no reasonable possibility that it contributed to the verdict.9 In this instance, where Dr. Shenkman’s reports constitute the vast majority of the medical evidence introduced by the Ridleys at trial, and most of their contents were not cumulative of other testimony, we cannot hold that the error was harmless.10 We therefore reverse the trial court’s denial of Lott’s motion for a new trial.

The Shigley Law Firm  represents plaintiffs in wrongful death and catastrophic injury cases statewide in Georgia, and in other states subject to the multijurisdictional practice and pro hac vice rules in each state. Ken Shigley was designated as a “SuperLawyer” in Atlanta Magazine and one of the “Legal Elite” in Georgia Trend Magazine. He is a Certified Civil Trial Advocate of the National Board of Trial Advocacy, Chair of the Southeastern Motor Carrier Liability Institute and former chair of the Georgia Insurance Law Institute. He particularly focuses on cases arising from truck wrecks and accidents (tractor trailers truck wrecks, semi truck wrecks,18 wheeler truck wrecks, big rig truck wrecks, log truck wrecks, dump truck wrecks.