Medical records in Romanian medico-legal assessments: requirements and limits

Medical record or medico-legal document?

A discharge summary, specialist letter, clinical chart or investigation report records medical care or findings. Article 9 of the Romanian Procedural Rules lists medico-legal expert reports, medico-legal findings reports, medico-legal certificates, analysis bulletins and medico-legal opinions as distinct categories. A clinical letter does not become a medico-legal certificate simply by being filed in a case. [1]

Clinical records are material for assessment. The forensic physician correlates them with the examination, investigations and questions in the case, explaining which conclusions they support and what remains uncertain. Considering a record does not mean automatically endorsing every diagnosis or establishing legal liability.

The central rule: Article 10 of the Procedural Rules

As amended in 2023, Article 10(1)(a) refers to records of the assessed person issued by healthcare units within the Ministry of Health’s own network or the healthcare networks of other ministries and institutions, and to foreign medical records that have been translated and legalised. [1]

Paragraph (1)(b) lists safeguards: a registration number, the healthcare unit’s stamp, and the physician’s signature and professional stamp identifying the specialty and physician code. Photocopies must carry a certified-true-copy endorsement, attested by the responsible physician. Paragraph (2) additionally allows other records to be considered where necessary to establish the diagnosis or answer the instructed questions. [1]

These provisions must be read together. The possibility of considering other relevant documents is not a general exemption from checking provenance and authenticity. An incomplete document may justify obtaining confirmation or a properly certified copy; it should not be represented as already meeting every requirement.

Originals, copies, private providers and foreign records

The simplified statement “only originals are accepted” is incorrect. Article 42 of the Regulation expressly provides for legible copies, complete copies of clinical documentation and extracts from registers. Copies must carry the true-copy endorsement and the responsible physician’s signature and professional stamp. The medico-legal institution may also request the original record of an investigation, with the provider retaining a copy and recording its transfer. [2]

A photograph sent by phone or an ordinary scan is not thereby a certified copy. A practical approach is to retain it for initial orientation and obtain the required version from its issuer. Do not add your own certification or alter the documents.

For private providers, Article 10(1)(a) should not be rewritten as if it explicitly listed all private facilities. However, paragraph (2) permits other relevant records, and Article 40 of the Regulation allows private providers to assist through consultations and investigations under a contract, subject to law. Read together, these provisions support avoiding automatic rejection solely because the provider is private; the actual use must be justified and verified within the assessment. This is a combined interpretation, not a guarantee of unconditional acceptance. [1, 2]

For records issued abroad, Article 10 requires translation and legalisation. A translation made by the patient or an automated tool does not fulfil the prescribed formalities. Supply the source document with a legalised translation and clarify the applicable requirements with the receiving institution in advance. [1]

Which records are useful for each assessment?

The table below is indicative. Not every document is needed in every case: requirements depend on the questions and the information already available. Investigations should be justified, rather than ordered merely to complete a checklist.

Assessment	Useful records	Purpose
Medico-legal certificate	Emergency records, discharge summaries, consultations, investigations and reviews	Injuries, chronology, treatment and course
Findings or expert report	Clinical records, earlier medico-legal documents and relevant case-file material	Answers to instructed questions, including causation and sequelae
Suspected medical negligence	Complete care records, monitoring, administration records, procedures and consent	Reconstruction of care and its consequences
Death investigation	History, emergency care, resuscitation, admissions, autopsy and complementary examinations	Correlation of disease and injury with the mechanism of death
Retrospective psychiatric assessment	Records close to the relevant date and case-file information	Mental capacity at the relevant time
REMA	Accident, treatment and follow-up records, together with examination	Accident-attributable consequences and trauma score

Medico-legal certificates: document the injury and its course

For injury assessment, useful records include the initial emergency attendance, investigations, hospital admissions, treatment and subsequent reviews. Recording the location, dimensions and appearance of injuries supports correlation. Article 43 of the Regulation requires detailed descriptions following medico-legal semiological rules in hospital records concerning cases involving a medico-legal investigation. [2]

For certification of recent traumatic injuries at the person’s request, Article 15(b) provides for examination before external injuries disappear and no later than 30 days after the event. This applies to that specific situation; it is not a universal deadline after which every expert assessment or medical record becomes unusable. Urgent medical treatment takes priority. [1]

Days in hospital, sick-leave days and days of medical care in the Romanian medico-legal sense are different concepts. A figure in a clinical document cannot simply be transferred into a medico-legal conclusion.

Suspected medical negligence: the complete clinical file

Where a possible deficiency in care is being investigated, the discharge summary provides an overview but may omit information needed to reconstruct decisions. Records from all involved providers may be relevant, including transfers, the pre-existing condition and the subsequent course.

In practice, the required material may include the complete clinical chart and attachments, emergency department records, interdisciplinary consultations, observation and monitoring charts, prescriptions and actual drug-administration records, nursing documentation, the operation note, anaesthetic chart, intensive-care records, laboratory and imaging results, transfusion records, consent forms and documented refusals. Depending on the questions, protocols applicable at the time and relevant information on care organisation may also be requested. [1, 2]

This is a practical recommendation, not a statutory inventory identical for every specialty. The analysis should identify what information was available when a decision was taken, what was prescribed, what was actually done, when, and with what result. A prescription alone does not prove administration; a signed consent form alone does not establish that an intervention was technically appropriate.

Article 27(1)(d) requires an expert commission for assessment of morbid conditions resulting from unlawful medical acts, deficiencies or failure to follow clinical guidelines and therapeutic protocols; paragraph (3) permits other biomedical specialists to participate at the commission’s request. The statutory description of this category does not justify presuming negligence before analysis. A complication or adverse outcome alone does not establish an attributable breach. [1]

Deaths and retrospective psychiatric assessments

In a death investigation, medical history, emergency and resuscitation records, hospital admissions, procedures and investigations are correlated with autopsy findings and complementary examinations. Histopathology, toxicology and microbiology address particular questions; their results should not be interpreted in isolation. Article 17 of the Rules specifies the status of complementary examinations. [1]

When assessing mental capacity at a past date, records close to that date may be particularly relevant. A later diagnosis does not automatically establish incapacity when a legal act was performed. Article 28(1) provides for direct examination by a commission, while paragraph (1¹) permits assessment of deceased persons on the basis of medical records and case-file information. This exception should not automatically be extended to living persons. [1]

Electronic records: preserve the original file

A digitally signed PDF and a photograph of a document are different. Article 4 of Law no. 214/2024 gives a qualified electronic signature the legal effect of a handwritten signature and separately regulates other situations. A document should not be rejected merely because it is electronic: the signature, integrity, issuer and applicable special requirements must be checked. [5]

Keep the file received from the issuer, not only a printout or screenshot, which do not allow the same technical verification. An image of a physician’s stamp inserted in a PDF does not, by itself, establish the presence of a qualified electronic signature. Where available, preserve original investigation images together with their medical interpretation.

Incomplete, conflicting or later records

A suspected diagnosis must be distinguished from a confirmed diagnosis, and the patient’s account from an objective finding. Differences in laterality, date, mechanism or diagnosis should be addressed by comparing records and, where necessary, obtaining clarification from the issuer; they should not be silently corrected.

Absence of an entry does not automatically prove that an action was not performed, but it may prevent verification. Equally, a retrospective explanation does not replace contemporaneous documentation without scrutiny. This is an interpretative precaution, not a rule invalidating all later records.

Article 24 permits requests for necessary case-file material and measures enabling further examinations or investigations. Paragraph (3) provides for assessment solely on documents in exceptional cases, without overriding special rules. Where a healthcare provider’s unjustified refusal prevents the work, Article 25 provides for notifying the judicial authority that ordered the assessment. [1]

How can patients obtain copies, and who may access them?

Article 24 of Law no. 46/2003 recognises patients’ access to their personal medical data. Article 9 of the Rules approved by Order no. 1,410/2016 provides for a written request and release of copies within a maximum of 48 hours after registration of the request. This deadline concerns copies requested under that procedure, not completion of a medico-legal expert report. [3, 4]

Identify the admission or consultation, dates and records requested; for a complex case, expressly request the complete file and attachments. Keep the registration number. If the records are intended for medico-legal use, specify the need for certification under the applicable requirements.

Confidentiality continues after death. Relatives or representatives do not automatically have unrestricted access. The designation, mandate or applicable legal basis must be established; Article 24 includes specific conditions for post-mortem access where the patient could not express consent. A medico-legal institution’s request under its statutory powers has a different legal basis from a relative’s request. [2, 3]

Where does a REMA report fit?

The insurance medicine assessment report has its own framework under Joint Order no. 1/2,293/2022. Article 4 requires a clinical examination and review of relevant records, substantiation of diagnoses and differentiation of accident-related consequences from other conditions. Insufficient documentation may be supplemented, and additional examinations are requested with the patient’s explicit consent. [6]

A REMA report must not be confused with a medico-legal certificate or a judicial expert assessment of suspected medical negligence. The same clinical records may inform several assessments, but their questions, procedures and intended conclusions differ.

Preparing the file: a practical checklist

Arrange records chronologically, retain all pages and attachments, check identity and dates, separate pre-event records from later ones, and include investigation images with their reports. Identify records that are missing or still requested. For foreign and electronic documents, preserve the source version and complete the required formalities.

A complete file is not one selected to support a predetermined conclusion. Documents that contradict a hypothesis may be as important as those supporting it. A credible medico-legal conclusion explains both what can be established and the limitations of the available information.

Official sources

Legal references checked on 23 September 2026. English explanations refer to Romanian law; the authoritative texts are in Romanian. Practical lists and interpretative recommendations are identified as such.