Reasonable Cause Affidavit (Certificate of Merit) - Arkansas

OPTIONAL EXPERT REVIEW STATEMENT — ARKANSAS MEDICAL INJURY

TABLE OF CONTENTS

1. Caption
2. Introduction and Purpose
3. Affiant Identification
4. Affiant Qualifications
5. Materials Reviewed
6. Familiarity with the Applicable Standard of Care
7. Statement of the Standard of Care
8. Opinion as to Breach of the Standard of Care
9. Opinion as to Proximate Causation
10. Reservation of Opinions
11. Verification and Notarization
12. Counsel's Filing and Service Control

1. Caption

IN THE CIRCUIT COURT OF [COUNTY] COUNTY, ARKANSAS
[___]TH JUDICIAL CIRCUIT — [CIVIL] DIVISION

Case No.: [____________________]

OPTIONAL EXPERT REVIEW STATEMENT — NOT A STATUTORY CERTIFICATE OF MERIT

2. Introduction and Purpose

STATE OF [____________________]
COUNTY OF [____________________]

I, [AFFIANT FULL NAME], [DEGREE: M.D. / D.O. / D.D.S. / etc.], after being duly sworn and on my oath, depose and state as follows:

1. I am of legal age, of sound mind, and competent to make this affidavit. The statements set forth herein are based on my personal knowledge, my education, training, and clinical experience, and my review of the materials identified below.

2. This optional statement records the opinions currently supplied to counsel concerning the proposed claims against the persons identified above. It is not prepared under Ark. Code Ann. § 16-114-209, which the Arkansas Supreme Court superseded effective April 1, 2015, and it is not to be filed or served unless counsel identifies independent current authority or a case-specific purpose.

3. I have been retained by [PLAINTIFF'S COUNSEL FIRM] to review the medical care provided to [PATIENT NAME / DECEDENT NAME] and to render opinions concerning the applicable standard of care, whether that standard was breached, and whether any such breach was a proximate cause of the injuries claimed.

3. Affiant Identification

4. My name is [AFFIANT FULL NAME].

5. My professional address is [INSTITUTION / PRACTICE NAME], [ADDRESS], [CITY], [STATE] [ZIP].

6. I am a [SPECIALTY, e.g., "board-certified emergency medicine physician"] currently engaged in the active clinical practice of medicine in [STATE].

7. I am [licensed to practice medicine in the State of [____________________], License No. [____________]; / and licensed in additional jurisdictions as listed in my curriculum vitae attached hereto as Exhibit A].

4. Affiant Qualifications

8. I received my [degree] from [MEDICAL SCHOOL] in [YEAR].

9. I completed an [internship / residency] in [SPECIALTY] at [INSTITUTION], [CITY, STATE], from [YEAR] to [YEAR], and [a fellowship in [SUBSPECIALTY] at [INSTITUTION] from [YEAR] to [YEAR]].

10. I am board-certified by the [SPECIALTY BOARD] (initial certification [YEAR], most recent recertification [YEAR]).

11. For the past [____] years, I have actively practiced [SPECIALTY] in [SETTING — e.g., "academic tertiary-care emergency departments", "community hospital", "outpatient clinic", "operating rooms"], and during that time have personally [provided care of the type at issue in this case / supervised residents and fellows providing such care / served on hospital quality and credentialing committees responsible for such care].

12. I have published [____] peer-reviewed articles in [SPECIALTY] and have lectured at [_____________________________].

13. My current curriculum vitae, identifying my education, training, board certifications, hospital affiliations, academic appointments, publications, and prior expert engagements, is attached as Exhibit A and incorporated herein by reference.

14. My experience and qualifications encompass the type of medical care at issue in this case, namely [the type of care: e.g., "the emergency-department evaluation of adult patients presenting with acute chest pain", "the management of post-operative anastomotic leaks", "the radiologic interpretation of [STUDY TYPE]"]. I am engaged in the same type of medical care as is each medical care provider defendant whose conduct I address herein.

5. Materials Reviewed

15. In forming the opinions expressed in this affidavit, I have reviewed the following materials:

☐ Complete medical records of [PATIENT NAME] from [FACILITY / PROVIDER], for the period DATE through DATE, including [admission and discharge summaries, physician orders, progress notes, nursing notes, medication administration records, laboratory results, imaging studies and reports, operative and procedure notes, anesthesia records, pathology reports, and consultation reports];

☐ Imaging studies [list studies and dates], reviewed in [DICOM / film / report] form;

☐ Pathology slides and reports [if applicable];

☐ Pre-incident medical records from [PRIOR PROVIDERS] for [DATE RANGE];

☐ Post-incident medical records reflecting subsequent treatment and outcome;

☐ Autopsy report dated DATE [if applicable];

☐ Death certificate [if applicable];

☐ Deposition transcripts [if available];

☐ Relevant policies, procedures, and protocols of [DEFENDANT FACILITY], including [identify policies if produced];

☐ Relevant peer-reviewed medical literature, including [list key references];

☐ Other materials: [identify].

16. I have reviewed sufficient materials to form the opinions expressed herein to a reasonable degree of medical certainty.

6. Familiarity with the Applicable Standard of Care

17. I am familiar with the standard of care applicable to physicians practicing [SPECIALTY] in [GEOGRAPHIC LOCALITY OR SIMILAR LOCALITY] at the time the care at issue was rendered (on or about DATE).

18. My familiarity with the applicable standard derives from:

☐ My personal clinical practice in [SPECIALTY] over the past [____] years, including practice in [identify settings comparable to the locality at issue];

☐ My participation in the training of [SPECIALTY] residents and fellows;

☐ My review of authoritative texts and peer-reviewed literature in [SPECIALTY];

☐ My participation in [specialty society guidelines / consensus statements];

☐ My participation in hospital quality, credentialing, peer-review, and morbidity-and-mortality processes; and

☐ My ongoing continuing medical education.

19. The standard of care for the conduct at issue in this case did not vary materially as between [LOCALITY OF CARE, e.g., "Pulaski County, Arkansas" / "Washington County, Arkansas" / "rural northwest Arkansas"] and similar localities at the relevant time. The standard reflects nationally recognized [SPECIALTY] practice as recognized by [SPECIALTY SOCIETY / GUIDELINE BODY].

7. Statement of the Standard of Care

20. The applicable standard of care required Defendant [PHYSICIAN / PROVIDER NAME], in the circumstances presented by [PATIENT NAME] on or about [DATE OF CARE], to:

☐ [Specific standard 1 — e.g., "obtain and document a focused history including time of onset, character, and radiation of chest pain, prior cardiac history, and risk factors"];

☐ [Specific standard 2 — e.g., "perform a 12-lead electrocardiogram within 10 minutes of arrival in any adult patient with chest pain"];

☐ [Specific standard 3];

☐ [Specific standard 4 — including any threshold for consultation, transfer, admission, surgical intervention, or specific medication administration];

☐ [Specific standard 5 — including documentation, communication of critical results, and discharge instruction requirements].

21. The standard of care required attention to the specific clinical findings present, including [identify the abnormal findings — e.g., "tachycardia of [____] bpm, hypoxemia with SpO2 of [____]%, troponin elevation, and acute ST-segment changes on ECG"], because [explain clinical significance].

8. Opinion as to Breach of the Standard of Care

22. Based upon my review of the materials identified above, I am of the opinion, to a reasonable degree of medical certainty, that Defendant [PHYSICIAN / PROVIDER NAME] departed from and breached the applicable standard of care in the following particulars:

☐ [Specific breach 1] — Defendant failed to [identify specific act/omission], when the standard of care required [specific action], as evidenced by [specific record reference, e.g., "the absence of any documented neurologic examination between [TIME] and [TIME] despite documented worsening mental status"].

☐ [Specific breach 2] — Defendant [identify breach with record references].

☐ [Specific breach 3] — Defendant [identify breach with record references].

☐ [Specific breach 4] — Defendant [identify breach with record references].

23. [If multiple defendants:] I have similarly reviewed the conduct of Defendant [SECOND PROVIDER NAME], and I am of the opinion that [HE/SHE] also breached the applicable standard of care in the following particulars: [list breaches with record references].

24. [If institutional defendant:] I have reviewed the policies, procedures, and staffing relevant to the care at issue, and I am of the opinion that Defendant [HOSPITAL / FACILITY] breached the standard of care applicable to a [type of facility] in [LOCALITY] in the following particulars: [list institutional breaches]. [If affiant lacks hospital-administration or nursing expertise, omit and use a separate affidavit.]

9. Opinion as to Proximate Causation

25. I am further of the opinion, to a reasonable degree of medical certainty, that the breaches of the standard of care identified above were a proximate cause of the injuries sustained by [PATIENT NAME], in that:

☐ Had Defendant [NAME] complied with the standard of care by [identify required action], it is more likely than not that [identify altered outcome — e.g., "the pulmonary embolism would have been diagnosed within the window during which thrombolytic therapy is effective", "the perforated viscus would have been surgically repaired before frank peritonitis developed", "the diabetic ketoacidosis would have been corrected before cerebral edema occurred"];

☐ The injuries described in the medical record (including [identify specific injuries — e.g., "anoxic brain injury", "below-knee amputation", "death"]) would not have occurred, or would have been substantially less severe, in the absence of the breaches identified.

26. The causal connection between the breaches and the injuries is established by [identify clinical reasoning — e.g., "the temporal sequence of clinical deterioration, the well-recognized natural history of the underlying condition, and the documented effectiveness of the omitted interventions in the peer-reviewed literature"].

10. Reservation of Opinions

27. The opinions expressed herein are based upon the materials reviewed to date. I reserve the right to supplement, expand, or modify these opinions upon receipt of additional records, deposition testimony, expert reports, or other materials produced during the course of this litigation.

28. This statement is not a statutory certificate and is not a complete recitation of every opinion the reviewer may later be asked to give. Counsel must manage any disclosure, supplementation, report, filing, or testimony obligation under the current rules, orders, and scheduling record that actually govern the matter.

11. Verification and Notarization

FURTHER AFFIANT SAYETH NAUGHT.

________________________________
[AFFIANT FULL NAME], [DEGREE]

ACKNOWLEDGMENT AND JURAT

STATE OF [____________________]
COUNTY OF [____________________]

Subscribed and sworn to before me this [____] day of [____________________], [______], by [AFFIANT FULL NAME], who is [personally known to me / proved to me on the basis of satisfactory evidence] to be the person whose name is subscribed to the foregoing instrument, and who acknowledged to me that [he/she] executed the same for the purposes therein contained.

________________________________
Notary Public

My commission expires: [__/__/____]

[NOTARY SEAL]

12. Counsel's Filing and Service Control

☐ Retain as attorney work product; do not file or serve.

☐ File or serve only under the following independently verified authority, order, or litigation purpose: [________________________________].

If filing or service is selected, record the date, recipient, method, authority, and confidentiality review here: [________________________________].

________________________________
[ATTORNEY NAME], Ark. Bar No. [____________]
[LAW FIRM NAME]
[ADDRESS]
[CITY], Arkansas [ZIP]
Telephone: [(___) ___-____]
Email: [____________________]

Attorney for Plaintiff

Sources and References

Statutory Authority

• Ark. Code Ann. § 16-114-206 — Burden of proof; expert testimony
• Ark. Code Ann. § 16-114-201 — Definitions
• Ark. R. Civ. P. 11 — Signing of pleadings; sanctions

Controlling Case Law

• Broussard v. St. Edward Mercy Health Sys., Inc., 2012 Ark. 14, 386 S.W.3d 385 (same-specialty clause of § 16-114-206 unconstitutional under Amendment 80)
• In re Arkansas Rules of Civil Procedure 11 and 42, 2015 Ark. 88 (§ 16-114-209 superseded effective April 1, 2015)

Practical Notes

• Do not file this as a statutory certificate. The 2015 Supreme Court order superseded § 16-114-209 in full, not merely its former 30-day deadline or dismissal language.
• Use the statement as an internal review aid unless current independent authority, an order, or a deliberate litigation purpose supports disclosure.
• Apply § 16-114-206's substantive proof framework and the current evidence rules without importing the invalidated same-specialty qualification.
• Tie every retained opinion to the reviewed record and identify assumptions, missing material, and limits.

Disclaimer

This optional review statement is not a filing requirement, legal opinion, or substitute for counsel's professional judgment. Confirm current Arkansas law and case-specific expert-proof requirements before deciding whether to disclose it.

Case Links

• In re Arkansas Rules of Civil Procedure 11 and 42, 2015 Ark. 88
• Broussard v. St. Edward Mercy Health System, Inc.