Order no. 16737 of 2024: The Assessment of Clinical Certifications and their Evidentiary Value

The recent order of the Court of Cassation, no. 16737 of June 17, 2024, offers important clarifications regarding the evidentiary value of attestations contained in a medical record. This decision is part of a complex legal context, where administrative certifications play a crucial role in civil and healthcare matters.

The Regulatory Framework for Clinical Certifications

The Court has established that attestations drawn up by a public hospital or an entity affiliated with the National Health Service (SSN) have the nature of administrative certifications. This means that the special regime provided for by Articles 2699 et seq. of the Civil Code applies to these attestations. This aspect is fundamental, as it confers a particular evidentiary value on these documents, different from other forms of assessment such as diagnoses or clinical opinions.

In general. Attestations contained in a medical record, drawn up by a public hospital or an entity affiliated with the SSN, have the nature of administrative certification - to which the special regime of Articles 2699 et seq. of the Civil Code applies - with regard to the indications contained therein of activities carried out during therapy or surgery (unlike assessments, diagnoses, or, in any case, statements of knowledge or opinion noted, which lack privileged faith), while activities not resulting from the record can be proven by any means. (In this case, the Supreme Court quashed the decision of the Court of Appeal not to assess the evidence through which the injured parties had proven the performance of an additional ecotocographic tracing, compared to those indicated in the medical record, erroneously assuming that the reliability and completeness of the latter can only be challenged through a false accusation).

Consequences of the Court's Decision

This ruling has significant consequences for legal practices in the healthcare sector. In particular, the Court quashed the decision of the Court of Appeal of Sassari, which had erroneously excluded the analysis of documentary evidence by the injured parties. This implies that, even in the absence of indications in the medical record, medical activities can be proven through other evidence, without the need for a false accusation.

• Medical records as administrative certifications.
• The possibility of proving activities not indicated in the record by any means.
• The role of false accusation in challenging clinical attestations.

Conclusions

In conclusion, order no. 16737 of 2024 represents a significant step towards greater protection of the rights of patients and injured parties in healthcare. By clarifying the value of clinical attestations and the possibility of using other evidence, this ruling offers new opportunities for those seeking justice in cases of medical malpractice. It remains essential for legal professionals to familiarize themselves with these legal aspects to ensure effective and informed defense.