Opinion ID: 1176271
Heading Depth: 2
Heading Rank: 3

Heading: Presumption of Completeness and Accuracy

Text: During Gage's delivery, both Phillips and delivery-room nurse Barbara Leng kept notes in Colleen Miller's medical chart. At trial, the Millers contended that Phillips's and Leng's testimony did not conform to their notes; they proposed an instruction that presumed the notes to be accurate and shifted to Phillips the burden of proof as to any facts reflected in the trial testimony that varied from the notes: It is the duty of Health Care providers such as Cate Phillips and Nurses working under her to describe accurately and fully in their medical records kept in the course of treatment everything of consequence that was done or observed during the course of treatment. The medical records kept during the course of the delivery of the child, Gage Miller, in this case are therefore to be accepted by you as accurate and complete. To the extent that you are asked to interpret the records differently from the manner and the way [they are written] the burden of proof lies with the party asking you to do so as the law presumes the records to be accurate and complete as stated above. The trial court declined to give the Millers' proposed instruction, stating, I don't see this as a legal issue at all. I think it's a factual issue that you can argue. On appeal, the Millers complain that the medical records were incomplete because they did not contain a description of the procedures that [Phillips] testified she used in relieving the shoulder dystocia. Citing Patrick v. Sedwick, 391 P.2d 453 (Alaska 1964), and Sweet v. Sisters of Providence in Washington, 895 P.2d 484 (Alaska 1995), they renew their claim of entitlement to an instruction on Phillips's duty to maintain accurate and complete medical records, and they argue that the trial court erred in rejecting their proposed instruction. We find this argument unpersuasive. Although the first paragraph of the Millers' proposed instruction accurately described Phillips's duty to keep full and accurate notes, see Patrick, 391 P.2d at 457, the second paragraph's legal presumption of accuracy, with its burden-shifting provision, finds no precedent in our case law. The authorities cited by the Millers do not support their requested presumption. In Patrick, the plaintiff, Patrick, awoke from thyroid surgery to find that her voice box had been permanently injured. See id. at 454. At trial, her surgeon had no recollection of the operation. See id. at 455. His surgery notes, which were made the day after the operation and were incomplete, did not refresh his recollection. See id. Because no other witnesses were capable of describing the operation, Patrick was unable to present affirmative evidence establishing her surgeon's negligence. See id. at 456. On these facts, Patrick held that the incomplete surgery notes could not be relied on to establish an absence of negligence. See id. at 457-58. The court concluded that proof of the unexplained injury constituted prima facie evidence of malpractice. See id. at 456. Patrick's core holding that the surgeon's incomplete notes could not be deemed accurate is entirely at odds with the Millers' proposed instruction, which required the jury to accept Phillips's allegedly incomplete notes as presumptively complete and accurate. In stark contrast to the situation in Patrick, the Millers' proposed instruction would have barred Phillips from relying fully on her actual recollections. Sweet is equally inapposite. There we found that a hospital's negligent loss of surgical records justified a burden-shifting spoliation instruction as to causation. See Sweet, 895 P.2d at 491. However, we expressly based this conclusion on two uncontroverted factors: the hospital's negligence in losing the records and the plaintiffs' inability to establish a convincing prima facie case of causation without them. See id. Here, in contrast to Sweet, there was no uncontroverted proof of lost or inadequate records. To the contrary, the adequacy and completeness of the medical records was a hotly disputed factual issue. [10] Nor did any alleged deficiencies in the delivery-room records hinder the Millers in presenting a prima facie case of malpractice. To the contrary, the purported deficiencies facilitated proof of the Millers' prima facie case by enabling them to attack Phillips's trial testimony as inconsistent with her notes and therefore incredible. The instructions as a whole adequately informed the jury as to relevant law. See Kavorkian v. Tommy's Elbow Room, Inc., 694 P.2d 160, 166 (Alaska 1985) (when reviewing a trial court's denial of a particular jury instruction, we consider whether the instructions as a whole adequately informed the jury of the relevant law). Given the disputed evidence concerning the completeness and accuracy of Phillips's delivery-room notes, we find no justification for a presumption reflecting the Millers' theory of their case. See Clary v. Fifth Ave. Chrysler Ctr., Inc., 454 P.2d 244, 251 (Alaska 1969) (affirming trial court's rejection of proposed jury instruction that defined duty only as it related to plaintiff's benefit). The trial court properly left the issues of completeness and accuracy to the jury. The trial court's decision rejecting the proposed jury instruction did not amount to error.