What is the current state of the law on the judicial treatment of clinical notes?

British Columbia, Canada


The following excerpt is from Fontaine v. Van Kampen, 2013 BCSC 1702 (CanLII):

Remarks highlighting the need to take care in the judicial treatment of clinical records along similar lines can be found in numerous additional authorities. Particularly apt here are the remarks of Griffin J. in Tsalamandris v. McDonald, 2011 BCSC 1138, para. 133: … A treating physician is not a scribe, writing down everything the patient says verbatim in anticipation of a future legal battle where every word and every absent word will be highlighted for significance. Nor is the patient shown the notes at the time, and so she has no opportunity to correct the misunderstanding of what the patient said.

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