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, provides important clarifications regarding the evidentiary value of the certifications contained in a medical record. This decision fits into a complex legal context, where administrative certifications play a crucial role in civil and health matters.

The Regulatory Context of Clinical Certifications

The Court has established that certifications issued by a public hospital or by an entity contracted with the National Health Service (SSN) are considered administrative certifications. This means that these certifications are subject to the special regime provided for in Articles 2699 and following of the Civil Code. This aspect is fundamental, as it gives such documents a particular evidentiary value, different from other forms of assessment such as diagnoses or clinical opinions.

In general, the certifications contained in a medical record prepared by a public hospital or by an entity contracted with the SSN are administrative certifications - to which the special regime of Articles 2699 and following of the Civil Code applies - concerning the indications contained therein of activities carried out during a therapy or intervention (unlike evaluations, diagnoses or, in any case, expressions of knowledge or opinion noted, lacking privileged faith), while activities not reflected in the record can be proven by any means. (In this case, the Supreme Court overturned the decision of the Court of Appeal not to consider the evidentiary results through which the injured parties had proven the occurrence of an additional echocardiographic tracing, compared to those indicated in the medical record, mistakenly assuming that the reliability and completeness of the latter could only be questioned by means of a false claim).

The Consequences of the Court's Decision

This ruling has significant consequences for legal practices in the healthcare sector. In particular, the Court annulled 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 demonstrated through other evidence, without the need for a false claim.

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

Conclusions

In conclusion, Order No. 16737 of 2024 represents a significant step towards greater protection of the rights of patients and victims in the health sector. By clarifying the value of clinical certifications 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 an effective and informed defense.

Bianucci Law Firm