Eficacia probatoria de las historias clínicas en los procesos judiciales que implican responsabilidad por muerte neonatal

Abstract

The obstetric-gynecologist (OBGYN) specialist and the personnel involved in the care of the newborn, can be legally liable in cases of neonatal death; in the medical record all the exams, assessments and procedure descriptions must be recorded, this document is private and therefore constitute documentary evidence as part of acquis in all types of legal proceedings. The general objective: identify the evidential efficacy of the medical records in the legal proceeding that imply responsibility for neonatal death in Colombia. Methodology: casuistry was performed with analysis and interpretation of sentences for lawsuits with medico-legal implications in OBGYN for neonatal death. Results: in one of the cases, the mother visited the health center (EPS) in five different occasions without providers foreseeing the existence of the cephalo-pelvic incompatibility of the fetus. In the second case, an ultrasound taken a month earlier with obvious evidence of coiling of the umbilical cord in the uterine cistern is not taken in consideration and after fail inductions, a cesarean section was performed but the neonate did not survive; there are clear failures in the care provided so a lawsuit is filed and eventually obligates the defendant to compensate the accuser for damages. Conclusions: The medical record as a probative document leads the judges and the different jurisdictional bodies to detect flaws in the care process, even when the mother-child pair have an unregistered pre-existence and find it difficult to establish the causal link, with the cognitivemodel the judicial truth is established by protecting the rules of the burden of proof and sound criticism.