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Shpigel v. White12/10/1999
3(b)(6) expressly recognizes that a "diagnosis" may be part of a business record. Further, in appropriate cases, this exception to the hearsay rule may apply where the proponent of the record seeks to use it to prove a causal connection between some trauma and a claimed physical injury. Lee v. Housing Authority of Baltimore, 203 Md. 453, 101 A.2d 832 (1954), is illustrative. In that case the plaintiff's decedent died from burns suffered in a fire in the pantry area of her apartment leased by her and her husband from the defendant. The plaintiff sought to introduce as substantive evidence the record from the hospital emergency room which included the statement that the patient had been admitted "following the explosion of a gasoline water heater in a confined area." Id. at 459, 101 A.2d at 834 (italics omitted). This Court held that the quoted portion of the hospital record should have been admitted by the trial court. It was pathologically germane.
The Court explained:
"In the instant case we think the record of the alleged cause of the burns to be treated was a proper part of the medical history. The entries do not undertake to establish the cause of the explosion, but merely relate to the nature of the substance causing the burns, gas, and the character of the combustion, an explosion. It is certainly customary and proper to record the type of accident causing the injury , and this information may have an important bearing upon the diagnosis, as indicating what the doctors should look for, and upon the treatment to be applied. We think the information recorded, from whatever source obtained, was not outside the regular course of professional inquiry." Id. at 460-61, 101 A.2d at 835.
Scott v. James Gibbons Co., 192 Md. 319, 64 A.2d 117 (1949), involved the use of hospital records by the plaintiff in a fatal automobile accident case.
There this Court said:
"Of course such records are admissible, and statements therein showing the history of the patient's physical condition are proper. History in this connection means the physical background as well as the present condition of the patient. It is proper for the record to show the patient was hurt in an automobile accident, but the particulars of such accident, contained in a hospital record, should be deleted and not submitted to a jury in a case like this. This is hearsay." Id. at 330, 64 A.2d at 122.
In the instant matter the computer generated discharge instructions for each plaintiff begin in part by saying, "Our doctors and staff appreciate your choosing us for your emergency medical care needs." The next section headed, "Motor vehicle accidents," is the same for each plaintiff.
In part it reads:
"You have suffered injuries in a car crash. Although you have been injured, hospital care does not appear to be needed right now. ... These minor injuries are usually much better after 3 days."
The printouts for the two children next contain "additional instructions" and "follow up care" sections. Benjamin was advised to "follow up with your pediatrician if needed," and Daniela was advised to rest and follow-up with her pediatrician. In another section of their instructions the children respectively were advised to call the pediatrician "as soon as possible."
The discharge instructions for Shpigel contain additional sections headed "Muscle strain," "neck injuries," "heat therapy," "prescriptions," and "Ibuprofen." Under the "neck injuries" section the record states: "Your exam shows you have strained the muscles and ligaments in your neck. This injury is very common in car accidents."
The circuit court found that the partic
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