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Shpigel v. White12/10/1999
ular hospital records proffered in this case were not trustworthy. We hold that, in so finding, the court acted within its discretion. It is apparent from the face of the Northwest Hospital emergency room discharge instructions that they are not traditional hospital records. They are an aggregation of pre-programmed, computer-generated paragraphs - in a word, they are boilerplate.
Looking at the admissibility issue from its most fundamental aspect, the hospital may not even have intended that the discharge instructions express an opinion whether there was any bodily injury or any need for emergency room treatment. The sentence, "You have suffered injuries in a car crash," may be simply a "plain language" way of stating the history given by the plainitff and not a medical diagnosis that there were injuries. Similarly, the sentence, "Our doctors and staff appreciate your choosing us for your emergency medical care needs " may be no more than a discrete way of saying, "Thanks for your business," and not an opinion that emergency room treatment was reasonably necessary.
If we assume that the statement, " lthough you have been injured" is intended to be a diagnosis, it is so general as to be of little help to a jury. The statement that appears only in Shpigel's discharge instructions to the effect that he has suffered a strain of the muscles of the neck, appears to be intended as a diagnosis. The record, however, is unclear as to who made the assumed diagnosis. The discharge instructions are not signed by the physician who is identified as having examined the plaintiffs. The person who does sign the discharge instructions does so above a line marked "Staff Signature," but the qualifications of that person are unknown. Also unknown is whether the examining physician specifies which boilerplate paragraphs are to be printed or whether the staff person decides which paragraphs are appropriate, based on information received. Records of a regularly conducted business activity "may be excluded if the method or circumstances of the preparation of the record indicate that the information in the record lacks trustworthiness." Rule 5-803(b)(6). Further, without live testimony in the instant matter, the jury would be left ignorant of how restricted the physician might be, within the computer program's menu of boilerplate paragraphs, in matching the actual findings to the available print-outs. For example, could the physician have printed out specific objective findings of the examination, if that were the case, or have printed out that the diagnosis was based entirely on subjective complaints, if that were the case?
In this litigation the visits to the emergency room are the first steps in Shpigel's claim of total disability and in the claim on behalf of the children for psychological harm. Those claims are vigorously contested, and the circuit court permissibly could conclude that medical evidence offered to support the first steps should be subject to cross-examination. Thus, although in many cases emergency room records, when authenticated and pathologically germane, may be readily admitted pursuant to Rule 5-803(b)(6), under the facts of this case the circuit court did not abuse its discretion in ruling that the discharge instructions were not admissible.
III.
For all of the reasons stated above, the judgment of the Circuit Court for Baltimore County is affirmed.
JUDGMENT OF THE CIRCUIT COURT FOR BALTIMORE COUNTY AFFIRMED. COSTS TO BE PAID BY MARK SHPIGEL, ONE OF THE APPELLANTS.
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