Ideological Forgery in Medical Records: Cassation Ruling 17647/2025 and the Privileged Faith of Public Deeds

The medical record is not a mere medical note, but a document of fundamental importance, whose correct keeping has legal implications of no small consequence. The recent ruling by the Court of Cassation, Ruling no. 17647 of 09/05/2025, offers a valuable opportunity to reflect on the legal nature of this document and the serious consequences that may arise from its manipulation or incompleteness. The decision annuls with referral the judgment of the Court of Appeal of Catanzaro, placing crucial emphasis on the principles of truthfulness and completeness of annotations.

The Legal Nature of the Medical Record: An Essential Public Deed

The heart of the matter lies in the qualification of the medical record as a "public deed endowed with privileged faith." But what does this mean exactly? In our legal system, a public deed is a document drawn up by a public official (in this specific case, a doctor in a public healthcare facility) in the exercise of their duties. "Privileged faith" implies that what is attested in such a deed constitutes full proof, until a claim of falsehood, of the origin of the document from the public official who prepared it, as well as of the declarations of the parties and other facts that the public official attests to have occurred in their presence or to have been carried out by them. This status is conferred by art. 2700 of the Civil Code and is reflected in the Criminal Code, particularly in arts. 476 and 479 c.p., which respectively penalize material forgery and ideological forgery in public deeds.

The Supreme Court, with the ruling in question, reiterates a consolidated principle: the medical record is the diary of the course of the illness and of all relevant clinical events. This means that every fact, every intervention, every observation must be noted with the utmost precision and, above all, in a timely manner. No implicit reference to other acts or documents is permitted, as the medical record must be a self-sufficient and faithful summary of the patient's clinical history.

In matters of crimes against public faith, the medical record drawn up by a doctor in a public healthcare facility has the nature of a public deed endowed with privileged faith and serves as a diary of the course of the illness and other relevant clinical events, so that facts must be annotated concurrently with their occurrence, must comply with the criteria of truthfulness of the representative content, completeness and continuity of information, and implicit reference to other documents is not allowed.

This maxim of the Cassation is definitive and clear. It establishes that the doctor has the obligation to annotate facts concurrently with their occurrence, ensuring:

• Truthfulness of the representative content: the annotations must correspond to the reality of the facts.
• Completeness: the record must contain all relevant information, without omissions.
• Continuity of information: the clinical narrative must be logical and without inexplicable interruptions.
• Concurrence: events must be recorded at the time they occur, or as soon as possible.
• Absence of implicit references: all information must be explicitly stated in the record itself, without deferring its understanding to other documents that are not directly consultable or attached.

The Specific Case and Practical Implications

The case that led to the Cassation ruling concerned the defendant P. P.M. E. T., a gynecologist, head of a surgical team, accused of ideological forgery in a public deed. Specifically, the annotations in the medical record relating to an emergency cesarean section, following which the patient unfortunately died, were deemed untrue and incomplete. The Court of Appeal had excluded the crime, arguing that the omitted or altered circumstances should have been reported in the different anesthesiology record, as the appropriate place for the description of hypoxic problems and the intervention of the anesthesiologists. However, the Cassation demolished this interpretation, annulling the decision. The Supreme Court reiterated that the surgical medical record, as a public deed, must be complete in itself and cannot delegate the burden of representing the truth of the facts to other documents. The separation of documents within a healthcare facility does not justify the fragmentation of the overall clinical truth.

This decision has a significant impact on the professional liability of healthcare personnel. Every doctor is called upon to draw up the medical record with the utmost diligence, aware that every annotation (or its omission) can have important legal repercussions. It is not just a matter of medical accuracy, but of adherence to a public duty of truth.

Conclusions: The Importance of Impeccable Documentation

Ruling no. 17647/2025 of the Cassation serves as a warning to all healthcare professionals. The medical record is a document that protects both the patient, ensuring transparency and traceability of the care pathway, and the doctor, providing objective proof of their work. Its drafting must be impeccable, adhering to the principles of truthfulness, completeness, continuity, and concurrence, leaving no room for ambiguous interpretations or implicit references. Any omission or alteration can constitute the serious crime of ideological forgery in a public deed, with the resulting criminal consequences. Accuracy in clinical documentation is not an option, but an indispensable obligation that ensures the proper administration of justice and the protection of public health.