A patient claim: the medical record is the defence, not the argument
Nextica Law & Tax defends healthcare centres and their professionals against patient claims: analysing the case with the expert report before replying, coordinating with the insurer and the broker from the first notification, defence in civil proceedings for professional liability and, where it arises, in criminal proceedings, responding to the pre-action claim and to mediation, and acting in the file opened by the professional body or the health authority. With the evidence set out before the narrative: in this sector the case is won or lost on the clinical documentation.
The claim arrives months later. By then, the only thing speaking for the centre is what was written down on the day of the visit.
What's included
1. Notifying the insurer of the incident within the period the policy requires, before replying to the patient in writing.
2. Securing the evidence
the complete medical record with its audit trail, consent for that specific treatment, images, laboratory records and communications.
3. Your own expert report assessing whether the treatment met the required standard, before deciding strategy.
4. Responding to the pre-action claim and taking part in mediation where it exists, with the position already settled.
5. Civil defence for professional liability, coordinated with the insurer and the broker.
6. Criminal defence if proceedings open, with a single account consistent with the one given elsewhere.
THE MEDICAL RECORD IS THE DEFENCE, NOT THE ARGUMENT
The argument is rarely about whether there was harm: it is about whether the treatment met the required standard and whether the patient was informed. Both are proved with documents.
Replying to the patient before notifying the insurer
almost every policy requires the incident to be notified within a short period of becoming aware of it, and replying on your own account can admit facts, alter the insurer's position or compromise the defence.
art. 16 of Law 50/1980 on Insurance ContractsA sparse record or one with generic notes
it does not prove malpractice, but it leaves the centre unable to prove good practice. In a liability case, that weighs as much as evidence against you.
Law 41/2002 on patient autonomyConsent that does not match what was done
if the signed document describes one treatment and another was performed, or does not cover the specific risks that materialised, the information given to the patient is unevidenced however thoroughly it was explained verbally.
Law 41/2002 on patient autonomyFrequently asked questions
A patient has filed a claim. What comes first?
Notify the insurer, and do not reply in writing before the case has been analysed. Almost every policy requires notification of the incident within a short period of becoming aware of it, and replying on your own account —even with the best intentions— can admit facts, alter the insurer's position or compromise the defence. Second, secure the evidence: assemble the complete medical record with its audit trail, the consent signed for that specific treatment, the images, the laboratory work orders and the communications with the patient. Third, and only then, decide the strategy.
Why do medical records decide so many cases?
Because the argument is rarely about whether there was harm, but about whether the treatment met the required standard and whether the patient was informed. Both are proved with documents: the progress recorded visit by visit, the alternatives explained, the specific risks communicated, and consent matching what was actually done. A sparse record, with generic notes or gaps, does not prove malpractice — but it leaves the centre unable to prove good practice, and in a liability case that weighs heavily.
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