Is a complete absence of a clinical record relevant to the evidentiary use of the records?

British Columbia, Canada


The following excerpt is from Bramley v. Lee, 2016 BCSC 1105 (CanLII):

In Edmondson v. Payer, 2011 BCSC 118, aff'd 2012 BCCA 114, N. Smith J. provided instructive commentary on the evidentiary use of clinical records including the relevance of their absence. At para. 37 he remarked: The same applies to a complete absence of a clinical record. Except in severe or catastrophic cases, the injury at issue is not the only thing of consequence in the plaintiff's life. There certainly may be cases where a plaintiff's description of his or her symptoms is clearly inconsistent with a failure to seek medical attention, permitting the court to draw adverse conclusions about the plaintiff's credibility. But a plaintiff whose condition neither deteriorates nor improves is not obliged to constantly bother busy doctors with reports that nothing has changed, particularly if the plaintiff has no reason to expect the doctors will be able to offer any new or different treatment. Similarly, a plaintiff who seeks medical attention for unrelated conditions is not obliged to recount the history of the accident and resulting injury to a doctor who is not being asked to treat that injury and has no reason to be interested in it.

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