Legal Question in Health Care Law in Florida

hearsay in medical charts

Is it legal for a doctor to enter hearsay into a patient's chart? My husband called his Mother's doctor to inquire about her current health. She is very ill. My husband mentioned that she was rather depressed, (just sitting and staring off into space) the last time he saw her and asked if she had been prescribed anti depressants. She had been but was not taking them. The doctor entered into her chart that she was ''near catatonic'' she has now been disqualified for a clinical trial based upon that non-observation. Is that legal?


Asked on 4/29/09, 5:45 pm

1 Answer from Attorneys
Alan Wagner Wagner, McLaughlin & Whittemore P.A.

Re: hearsay in medical charts

Yes. It is perfectly fine for a doctor to enter hearsay information in a chart. Happens all the time and is, in fact, appropriate in almost all cases. In terms of patient care, the more information the better. The doctor is in the best position to evaluate the reliability of the information.

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Answered on 4/29/09, 5:51 pm


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