THE IMPORTANCE OF THE MEDICAL RECORD IN MEDICAL EXPERTISE

Abstract

The increasing judicialization of healthcare has generated professional insecurity and potential damage to the quality of medical services, reflecting the fear of medical malpractice lawsuits with high indemnity values. In this context of increased civil liability against doctors and hospitals, conviction frequently does not stem from an error in clinical practice itself, but from the difficulty in proving ethical and technical conduct due to the precariousness of medical record keeping. The absence of detailed documentation makes the legal defense vulnerable. This study analyzes the legal and technical value of the medical record as an essential instrument of proof to combat medical malpractice convictions and highlights its fundamental role in judicial expertise (medical examination) and in the judge's conclusion. The methodology adopted was exploratory in nature, applying the deductive method to the analysis of legal doctrines, federal legislation, and regulations of the Federal Council of Medicine (CFM). To validate the theory, an empirical study was conducted on 14 judgments issued by the Court of Justice of the State of Rio de Janeiro (TJRJ) in 2020, using the descriptors "medical record" and "medical error," seeking to integrate ethical and legal concepts and demonstrate the documentation’s influence on judicial sentences. The analysis concluded that the medical record, besides being a multidisciplinary piece for clinical follow-up, is the most relevant document for dispute resolution and the primary documentary evidence for indirect expertise (based on records). However, it was also found that the lack of ethical and legal knowledge among healthcare professionals is a crucial factor contributing to judicialization. It becomes imperative to understand the medical record not merely as an assistance record, but as an invaluable legal protection tool. Diligence in record keeping is the factor that profoundly impacts the interpretation of magistrates and judicial experts, being essential for the correct differentiation between culpable medical error (imprudence, negligence, or incompetence) and harm derived from iatrogenesis or medical intercurrence.