Notable Medical Malpractice Discovery Decision by Judge Terrence R. Nealon of Lackawanna County

In the recent Lackawanna County Court of Common Pleas decision in the case of Baker v. Geisinger Community Medical Center, No. 2016-CV-2946 (C.P. Lacka. Co. April 7, 2017 Nealon, J.), Judge Terrence R. Nealon addressed a Plaintiff’s Motion to Compel a hospital in a medical malpractice action to produce the “audit trail” for her electronic medical records from the date of the Plaintiff’s admission to the hospital up to the present.  

Judge Terrence R. Nealon
Lackawanna County

Judge Nealon noted that the audit trail documents every occasion that an electronic medical record is accessed, what specific information is reviewed, who entered or altered any information in the chart, what information was entered or later changed, who accessed, reviewed or added information to the chart, and when and where the activity occurred. 

The court noted that the Plaintiff produced deposition testimony reflecting disparities between the testimonial recollections of the healthcare providers and the entries contained in the hospital chart.   The court noted that the audit trail will reveal which healthcare providers reviewed what information, when they acquired that knowledge, where and when they made their respective entries, and whether those entries had ever been edited or altered.  

Judge Nealon noted that electronically stored information is discoverable if it is relevant and can be produced without undue cost, burden, or delay, and where substantially similar information is not available or readily accessible by less burdensome means. 

The court in Baker held that, since the audit trail is relevant to the claims at issue and may be secured and produced without significant cost or hardship, Plaintiff’s Motion to Compel was granted under the proportionality standard governing discovery requests for electronically stored information.  

Anyone wishing to review a copy of this decision may click this LINK

Anyone wishing to read this decision by Judge Nealon in the Baker case may click HERE.