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Legal protection · 03

The incomplete record.

A medical liability case is decided on the paperwork. A gap in the record can be read against whoever filled it in. On its own, though, it is not enough to find for the patient.

Information, not legal advice. Read on 12 October 2026.

Incomplete record

The rule

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Law 24 of 2017, article 7, paragraph 3

The healthcare professional "is liable for his own conduct under article 2043 of the civil code, unless he acted in performance of a contractual obligation undertaken with the patient". Anyone with a direct relationship with the patient, in his own practice, falls within that "unless".

Read the textNormattiva

Incomplete record

The precedents

Filed on 13 March 2025

Court of Cassation, Civil Division, Third Section, order 6645 of 2025

The facts
An eighty-year-old patient, two operations a few days apart, death. The heirs argue that the incomplete record is enough to prove the link between the treatment and the death. This is not an aesthetic medicine case.
What was decided
Appeal dismissed. "The incompleteness of the medical record is not legal proof": the judge may take it into account only if it made it impossible to establish the causal link and if the professional nevertheless engaged in conduct capable of causing the damage. In this case, the precautions that were not noted were considered not taken, but they would not have been enough to prevent the event.
Read the textItalgiureWeb, SentenzeWeb: search by number and year

Incomplete record

What protects the physician

  • Every act noted when it happens, with date, time and author: history, indication, consent, technique, product, lot, dose, site, complications, instructions given, follow-ups.
  • Notes that are not silently rewritten: a record counts as evidence if it is reliable.
  • The ability to hand over a complete copy within a few days.

In Fibonacci

  • A saved session is not silently rewritten: every change stays in the history, with who and when.
  • Empty sections of the file are declared, not omitted.
  • Every session downloads a PDF with product, batch, expiry, quantity, areas, technique, consents and photographs.

Incomplete record

What these sources do not say

The Court of Cassation, in the texts examined, does not say that a patchy medical record makes the doctor lose the case. It says the gap weighs against whoever wrote it, within precise limits. How long records must be kept and when the limitation period starts are not covered here.

Documentation must be done while you work, not when the lawyer's letter arrives.

In half an hour we show you how Fibonacci records consents, sessions, batches, and photos during the visit.

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