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AN ENTRY IN A HOSPITAL RECORD INDICATING PLAINTIFF FELL DOWN A FEW STAIRS WAS NOT GERMANE TO TREATMENT OR DIAGNOSIS AND WAS NOT AN ADMISSION BECAUSE THE SOURCE OF THE ENTRY WAS UNKNOWN; NEW TRIAL ORDERED IN THIS SLIP AND FALL CASE (SECOND DEPT).

The Second Department, reversing the defense verdict and ordering a new trial, determined an entry in the plaintiff’s medical records indicating she fell down a few stairs was inadmissible. Plaintiff alleged she fell through a broken step. The entry in the hospital record was not germane to diagnosis or treatment and the source of the entry could not be ascertained:

… Supreme Court should have precluded the admission into evidence of an entry in a medical record from … the Brookdale medical record … that indicated that the plaintiff sustained a “mechanical fall down ‘a few’ stairs.” An entry in a medical record that is not germane to diagnosis or treatment but is inconsistent with a position taken by a party at trial is admissible as an admission by that party only when there is evidence connecting the party to the entry … .. “[W]here the source of the information on the hospital or doctor’s record is unknown, the record is inadmissible” … .

Here, the Brookdale medical record was not germane to the plaintiff’s diagnosis or treatment, and thus was not admissible on that basis … .. Moreover, there was no showing that the plaintiff was the source of the information in that record and so it was not admissible as an admission by the plaintiff … . Fraser v 147 Rockaway Pkw, LLC, 2022 NY Slip Op 01772, Second Dept 3-16-22

Practice Point: An entry in a hospital record which is not germane to treatment or diagnosis is not admissible. An entry in a hospital record which is inconsistent with a plaintiff’s position at trial is admissible as an “admission” only if it is clear plaintiff was the source of the entry. If, as it was here, the source of the entry is unknown, it is inadmissible.

 

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