The Court of Appeals of Indiana (“Indiana Appellate Court”) held in its opinion filed on May 30, 2018 that the plaintiff failed to produce any evidence that would establish that the defendant podiatrist’s treatment of her fell below the applicable standard of care, and if the defendant did not breach his duty to the plaintiff, the plaintiff’s claim for medical malpractice fails as a matter of law.
The plaintiff had been treated by the defendant podiatrist over a period of five years during which the defendant operated on her right foot and ankle three times. Because she had continuing pain after her last surgery, the plaintiff sought a second opinion from another podiatrist who advised the plaintiff that her continuing pain was due to the last surgery.
The plaintiff filed her proposed medical negligence complaint against the defendant podiatrist with the Indiana Department of Insurance, pursuant to Indiana’s Medical Malpractice Act, alleging that in performing the surgery, the defendant failed to meet the appropriate standard of care for podiatry and orthopedic surgery, and as a proximate result of the failure of the defendant to meet the standard of care, the plaintiff sustained severe and permanent damage to her right foot and ankle and is permanently impaired.
The Medical Review Panel (“Panel”) reviewed the plaintiff’s complaint and the defendant’s patient records before issuing a unanimous opinion that the record keeping of the defendant failed to meet the required standard and that the lack of documentation makes it impossible for the Panel to decide whether the evidence supports or does not support a conclusion that the defendant failed to comply with the appropriate standard of care in his treatment of the plaintiff.
After the plaintiff filed her Indiana medical malpractice complaint in court, the defendant filed a motion for partial summary judgment and argued that Indiana law does not impose a legal duty on physicians to keep any particular type of patient medical records, and therefore the plaintiff does not have an actionable claim arising out of the defendant’s method of record keeping. The defendant further argued that even if the duty did exist, the plaintiff failed to establish a causal connection between the breach of that duty and her alleged injuries.
The trial court granted the defendant’s motion for summary judgment, and the plaintiff appealed.
Indiana Appellate Court Decision
The Indiana Appellate Court stated that in order to establish a prima facie case of medical malpractice, a plaintiff must demonstrate: (1) a duty on the part of the defendant in relation to the plaintiff; (2) a failure to conform her conduct to the requisite standard of care required by the relationship; and (3) an injury to the plaintiff resulting from that failure. The plaintiff must come forth with expert medical testimony establishing: (1) that the doctor owed a duty to the plaintiff; (2) that the doctor breached that duty; and (3) that the doctor’s breach proximately caused the plaintiff’s injuries.
A unanimous opinion of the medical review panel establishing that the doctor failed to comply with the appropriate standard of care and that the doctor’s conduct was a factor in causing the patient’s resultant damages is ordinarily sufficient to meet the patient’s initial burden to show that there was no genuine issue of material fact. The burden then shifts to the doctor to designate sufficient expert testimony setting forth specific facts showing the existence of a genuine issue of material fact.
The Indiana Appellate Court stated, “This is an extremely unusual case. There is no statutory authority or reported case law establishing a duty to maintain ‘adequate’ records. Indiana Code section 16-39-7-1 requires doctors to keep records, and it would not be unreasonable to conclude that the duty to keep records requires that the doctor’s records be adequate to determine what facts the doctor relied on to make a diagnosis, including the patient’s relevant medical history, and the course of treatment recommended by the doctor. At a minimum a doctor’s records should include sufficient information so that the Medical Review Panel can make a determination whether the doctor met the applicable standard of care. And if the sufficiency of medical records was a controlling factor in the determination of whether [the defendant’s] treatment of [the plaintiff] met the applicable standard of care, our review would end here.”
The Indiana Appellate Court continued, “However, even if we assume that a physician has a duty to keep adequate records, whether [the defendant] kept adequate records is a question of fact … We firmly believe that the presence or absence of medical records is certainly a factor in the determination of whether or not medical malpractice occurred in any case. However, in the face of an admissible affidavit from a competent expert opining that [the defendant’s] care of [the plaintiff] was within the applicable standard of care notwithstanding his extremely poor recordkeeping and deposition testimony from Panel members that the surgeries were adequately performed and appropriate for [the plaintiff’s] diagnosis, it is inadequate as a matter of law to respond solely by pointing only to the Panel’s finding that [the defendant’s] recordkeeping failed to meet the applicable standard.”
A concurring opinion stated, “I urge our Legislature to amend the Act to provide that health care providers have an affirmative duty to maintain adequate and accurate medical records and that a violation of that duty could support a prima facie medical malpractice claim … Nonetheless, we must strictly construe the Act, and because [the plaintiff] did not designate any evidence to show that [the defendant’s] conduct fell below the applicable standard of care, I am compelled to agree with the majority that summary judgment for [the defendant] is required.”
Source Henderson v. Kleinman, 84A01-1710-CT-2566.
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