                               THIRD DIVISION
                              ELLINGTON, P. J.,
                         DILLARD and MCFADDEN, JJ.

                    NOTICE: Motions for reconsideration must be
                    physically received in our clerk’s office within ten
                    days of the date of decision to be deemed timely filed.
                               http://www.gaappeals.us/rules/


                                                                       July 13, 2015




In the Court of Appeals of Georgia
 A15A0345. WONG et al. v. CHAPPELL et al.

      MCFADDEN, Judge.

      Ruth Oleana Wong died after undergoing a cryoablation of the endometrium,

a procedure to destroy a thin layer of the lining of her uterus through freezing. After

her death, her husband, Kwee Wong, filed this medical malpractice action. He appeals

the defense verdict in favor of doctors Mary L. Chappell, Kimberly A. Huffman, and

Terry V. Kelley, and their practice, OB-Gyn Associates, P.A.

      Wong argues that the trial court erred by refusing to charge the jury on simple

negligence. Because at least some of Wong’s allegations call into question only the

execution of administrative, clerical tasks, not the exercise of professional skill and

judgment, we agree and therefore reverse and remand. Since we are remanding, we

address Wong’s arguments that are likely to recur on retrial. Wong argues that the
trial court erred by refusing to instruct the jury on the unauthorized practice of

medicine and negligence per se. We agree because Wong presented some evidence

that an unlicensed medical assistant engaged in acts that required a medical license.

However, we reject Wong’s argument that the trial court erred by refusing to instruct

the jury that the printed material from the manufacturer of the cryoablation device –

the “package insert” and user’s manual – established the standard of care for the use

of the device. Although the printed material is relevant, expert testimony is required

to establish the standard of care. We reject Wong’s argument that the trial court erred

by admitting a resource guide published after Mrs. Wong’s procedure because he has

not shown that the trial court abused her discretion. We do not address Wong’s

argument that the trial court erred in directing a verdict on his punitive damages claim

because the resolution of that claim on retrial will depend on the evidence introduced.

Nor do we address his argument that the trial court erred in allowing defense counsel

to strike a juror for cause after the parties had begun exercising their peremptory

challenges because any such error is unlikely to recur on retrial.

      1. Facts.

      Mary Chappell, an obstetrician-gynecologist, performed a cryoablation on Ruth

Oleana Wong on October 4, 2010. Chappell performed the procedure in her office.

                                           2
      A few days after the procedure, Mrs. Wong began experiencing increased pain,

which radiated along her flank to her back. On October 13, Mrs. Wong called

Chappell’s office. She spoke to Lauren Gephart, an unlicensed medical assistant. She

told Gephart that she was experiencing pain radiating from her flank and back,

bleeding, and changes in her bowel movement. Gephart thought that Mrs. Wong

might have a urinary tract infection, so Gephart asked her whether she had any of the

typical symptoms. Gephart did not talk to any doctor, nurse practitioner, or

physician’s assistant about the back and flank pain or the bleeding because she did

not think Mrs. Wong’s complaints were sufficiently serious, although she may have

made a comment to Chappell in passing about Mrs. Wong’s question about her bowel

movement. Gephart told Mrs. Wong that her symptoms could be normal and advised

her to take 800 milligrams of Ibuprofen; Gephart had been instructed by the doctors

that she should advise patients to take 800 milligrams of Ibuprofen every eight hours

as needed for any sort of abdominal or back pain. Gephart was not authorized to make

medical diagnoses or to give medical advice, she testified, but one of the doctors in

the practice, defendant Kelley, testified that the medical assistants were authorized

to give medical advice that has been “supervised, taught, trained,” by the physicians

in the office. Huffman, another doctor-defendant, testified that Gephart should have

                                         3
asked Mrs. Wong the intensity, duration, and severity of her pain, and should have

notified Chappell if the pain was severe. Huffman testified that medical assistants

“are allowed to give clinically relevant information as instructed by their supervising

physician.”

      On October 17, Mrs. Wong went to the emergency room and was admitted to

the intensive care unit. In the early morning of October 18, Huffman, who was the on-

call doctor for OB-GYN Associates, saw Mrs. Wong. Later that day, Mrs. Wong

underwent exploratory laparoscopic surgery. Although another physician performed

the laparoscopy, defendants Chappell and Kelley were in the operating room;

Chappell had asked Kelley to be available to assist should Mrs. Wong need a

hysterectomy. Mrs. Wong’s uterus was “very boggy,” with a “dark, mottled”

appearance. Chappell and Kelley believed that the cryoablation could have caused

Mrs. Wong’s uterus to look that way. Chappell decided not to remove Mrs. Wong’s

uterus, and Kelley concurred in the decision because he thought that Mrs. Wong

would not survive a hysterectomy.

      Eleven days after she was admitted to the hospital, Mrs. Wong died. More than

two months after the cryoablation procedure – and after Mrs. Wong had died – Mrs.



                                          4
Wong’s written antibiotic prescription was found at the OB-GYN Associates office.

Chappell had written on the slip, “Found December 8, 2010, at front desk.”

      Wong filed this action individually and as executor of Mrs. Wong’s estate. He

alleged that Chappell perforated the wall of Mrs. Wong’s uterus during the

cryoablation, eventually leading to sepsis and necrosis; that when Mrs. Wong called

OB-GYN Associates about the resulting pain, Lauren Gephart failed to handle the

call appropriately; that when she consulted at the hospital, Huffman failed to give

Mrs. Wong care; and that Chappell and Kelley observed Mrs. Wong’s necrotic,

ischemic uterus during the exploratory laparoscopic surgery, but failed to perform a

hysterectomy. Wong sought damages for Chappell’s, Huffman’s, and Kelley’s

professional negligence and for OB-GYN Associate’s vicarious liability for Gephart’s

and the front desk staff’s negligence.

      After a 16-day trial, the jury returned a defense verdict. Wong filed this appeal.

      2. Refusal to charge the jury on ordinary negligence and instead charging that

professional negligence applied to all claims.

      Wong argues that the trial court erred by denying his request to charge the jury

on ordinary negligence and instead instructing the jury that the medical malpractice

standard of care applied to all of Wong’s claims. We agree.

                                          5
      Among his other allegations, Wong alleged that the defendants were

vicariously liable for the following acts of negligence:

      the front desk staff’s failure to ensure that Mrs. Wong took her antibiotic
      prescription with her after the procedure, failure to notice that the
      prescription was left at the front desk for more than two months, and
      failure to notify Mrs. Wong or Chappell that Mrs. Wong did not get the
      antibiotic;


      the staff’s failure to implement proper procedures for handling
      prescription slips and failure to maintain the front desk in an organized
      manner so that the slip would not be lost;


      medical assistant Lauren Gephart’s failure to properly note Mrs. Wong’s
      complaint of flank pain, failure to determine the severity, intensity and
      duration of her pain and continued bleeding, and failure to relay to a
      physician Mrs. Wong’s complaints;


      the failure to properly train Gephart regarding her phone triage duties.


      In support of his allegations regarding the prescription slip, Wong presented

evidence that Mrs. Wong’s written antibiotic prescription was found more than two

months after the procedure – and after Mrs. Wong had died– and that Chappell had

written on the slip, “Found December 8, 2010, at front desk.” In support of his

allegations regarding Gephart’s handling of Mrs. Wong’s telephone call, he presented

                                          6
the following evidence: Gephart’s testimony that although Mrs. Wong complained

of flank pain, which can originate in the pelvis, Gephart did not note flank pain on

Mrs. Wong’s chart because Gephart did not normally use that word and she

categorized such pain as “all in the same area.” Gephart did not recall asking Mrs.

Wong how long she had had the pain, whether the pain was sharp or dull, constant

or intermittent, its severity on a scale from one to ten, or whether her abdomen was

soft and distended. Mrs. Wong reported bleeding, but Gephart did not write down the

details. Gephart did not report Mrs. Wong’s telephone call to any doctor, nurse, or

physician’s assistant. Gephart was not really concerned about Mrs. Wong’s telephone

call. Gephart had been trained by two other medical assistants.

      “Claims of allegedly negligent administrative acts which do not require

professional knowledge or skill assert ordinary negligence.” Peterson v. Columbus

Med. Center Foundation, 243 Ga. App. 749, 754 (2) (533 SE2d 749) (2000). In spite

of Wong’s allegations and the evidence he presented in support of them, the trial

court refused to give the requested ordinary-negligence charge, reasoning that expert

testimony was required to prove causation. But that is not the standard. This is the

standard: only where the allegations of negligence against the professional involve

the exercise of professional skill and judgment within the professional’s area of

                                         7
expertise does the claim sound in professional negligence. Stafford-Fox v. Jenkins,

282 Ga. App. 667, 671 (2) (639 SE2d 610) (2006). Contrary to the trial court’s

rationale, simply because expert evidence is required to prove causation does not

mean that a case involves professional malpractice. See Cowart v. Widener, 287 Ga.

622, 627 (2) (a) (697 SE2d 779) (2010) (“[e]ven in simple negligence cases, plaintiffs

must come forward with expert evidence . . . where ‘medical questions’ relating to

causation are involved”); Ronald L. Carlson, Julian A. Cook III, and Michael Scott

Carlson, Trial Handbook for Ga. Lawyers § 24:21 (3d ed.) (“While expert evidence

is usually not required to prove causation in a simple negligence case, expert evidence

may be required where a medical question involving specialized medical knowledge

is needed in establishing causation, a causal link between a defendant’s conduct and

a plaintiff’s injury.”)

       The trial court erred by concluding that because expert testimony was required

to prove causation, all of Wong’s allegations asserted claims of professional

negligence. The allegations of negligence by the front desk staff, although asserted

against professionals – the obstetrician-gynecologist defendants – do not involve the

exercise of professional skill and judgment within the area of expertise of an

obstetrician-gynecologist. Similarly, Wong’s allegations that Gephart did not

                                          8
document Mrs. Wong’s complaint accurately and did not relay her complaint to a

doctor do not involve the exercise of professional skill and judgment within the area

of expertise of an obstetrician-gynecologist. Finally, Wong’s allegation that the

defendants failed to adequately train Gephart, an unlicensed medical assistant, to

handle patient calls, does not involve the exercise of professional skill and judgment

within their area of expertise. The permissible scope of a medical assistant’s duties

is set out in OCGA § 43-34-44, which allows medical assistants to perform certain

medical tasks, and the corresponding administrative rule, Ga. Comp. R. & Regs. r.

360-3-.05. The permissible activities set out in those provisions are fully

comprehensible by a layperson. Therefore any training that medical assistants are

authorized to receive must likewise be fully comprehensible by a layperson and such

training does not involve the exercise of professional skill and judgment.

Accordingly, these are claims of ordinary negligence. General Hosp. of Humana v.

Bentley, 184 Ga. App. 489, 491 (361 SE2d 718) (1987).

      We observe that in addition to the allegations about Gephart’s failure to

document Mrs. Wong’s complaint accurately and failure to relay the call to Chappell,

Wong alleges that some of Gephart’s actions amounted to the unlicensed practice of

medicine. As discussed in Division 3, infra, this is a question for the jury. Should the

                                           9
jury determine that some of Gephart’s actions amounted to the unlicensed practice of

medicine, then those actions would be held to the standard of care and skill of a

medical professional. Andrews v. Lofton, 80 Ga. App. 723, 729 (2) (57 SE2d 338)

(1950).

      Because some of Wong’s claims alleged ordinary negligence, the trial court

erred by refusing to give Wong’s requested jury charge on ordinary negligence. See

Taylor v. State, 272 Ga. 744, 745 (1) (534 SE2d 67) (2000) (“It is error to refuse to

give a charge . . . where the request is a correct statement of law that is pertinent and

material to an issue in the case and not substantially covered by the charge actually

given.”) (citation and punctuation omitted). And the court exacerbated that error by

instructing the jury that the professional negligence standard applied to all of Wong’s

claims. “When an error in the charge of the court is shown to exist, it is presumed to

be prejudicial and harmful, and this court will so hold unless it appears from the

entire record that the error is harmless.” Graham v. Fallick, 322 Ga. App. 525, 528-

529 (745 SE2d 747) (2013) (citation and punctuation omitted). It does not appear

from the record that these errors were harmless. Accordingly we reverse the judgment

entered on the jury’s defense verdict and remand this case for proceedings not

inconsistent with this opinion.

                                           10
      3. Failure to charge the jury on the illegal practice of medicine and negligence

per se.

      Wong argues that the trial court erred by failing to instruct the jury on the

unauthorized practice of medicine and negligence per se, as he requested. We agree.

      In essence, Wong contends that Lauren Gephart, the unlicensed medical

assistant, was not authorized to assess the severity of Mrs. Wong’s symptoms and to

instruct her to take Ibprofen, that doing so violated OCGA § 43-34-22, the statute

prohibiting the practice of medicine without a license, and that violation of this

statute amounted to negligence per se. The defendants counter that Gephart’s

interactions with Mrs. Wong were permitted under OCGA § 43-34-44, which allows

medical assistants to perform certain medical tasks, and the corresponding

administrative rule, Ga. Comp. R. & Regs. r. 360-3-.05.

      The statute, part of the Medical Practice Act of the State of Georgia, provides

in pertinent part, “Nothing in this article shall be construed to prohibit the

performance by medical assistants of medical tasks, including subcutaneous and

intramuscular injections; obtaining vital signs; administering nebulizer treatments;

or other tasks approved by the board pursuant to rule, if under the supervision by a



                                         11
physician in his or her office. . . .” OCGA § 43-34-44. The rule provides in pertinent

part:

        It shall be grounds for disciplinary action by the Board if a physician
        aids or abets another person in misrepresenting his/her credentials or
        engaging in unlicensed practice. Engaging in unlicensed practice
        includes delegation by a physician of professional responsibilities to a
        person who is not authorized to provide such services. A physician may
        delegate the performance of certain medical tasks to an unlicensed
        person with appropriate supervision as provided herein.


        (a) Medical Assistants: 1. For purposes of this rule, a medical assistant
        is an unlicensed person employed by the physician to whom he or she
        delegates certain medical tasks. (i) A physician may delegate to a
        medical assistant the following medical tasks: subcutaneous and
        intramuscular injections; obtaining vital signs; administering nebulizer
        treatments; or removing sutures and changing dressings. . . . (iv)
        Nothing in this rule prohibits the performance of tasks by medical
        assistants that would not otherwise require a license.


Ga. Comp. R. & Regs. r. 360-3-.05 (1).

        Reading the statute and rule together, it is clear that medical assistants may

perform certain specified medical tasks as well as tasks that do not require a medical

license. The question, then, is whether Gephart’s interaction with Mrs. Wong

involved a task that required a license. With some exceptions not pertinent here,

                                           12
OCGA § 43-34-22 (a) requires any person who “suggest[s], recommend[s], or

prescribe[s] any form of treatment for the palliation, relief, or cure of any physical or

mental ailment of any person” to have a medical license. Wong’s expert testified that

only a physician can handle complaints of post-operative pain, that medical assistants

should not give treatment advice, and that Gephart should not have told Mrs. Wong

that her symptoms were normal or instructed her to take Ibuprofen

. In their appellate brief, the defendants even state that “Gephart’s alleged negligent

acts required her to exercise independent medical judgment to decide . . . what to

advise Ms. Wong to do.” Whether it was appropriate for Gephart to perform these

medical tasks is a question for the jury. Cf. Cardio TVP Surgical Assocs. v. Gillis,

272 Ga. 404, 406 (1) (528 SE2d 785) (2000) (because physician assistants, unlike

medical assistants, are so heavily regulated by the Composite State Board of Medical

Examiners, only the Board can determine whether it is appropriate for a physician

assistant to perform a specific procedure). And if the jury should find that Gephart

performed tasks that required a license, she would have engaged in the unlicensed

practice of medicine. Such a finding would support Wong’s requested charges. Brown

v. Belinfante, 252 Ga. App. 856, 861 (1) (557 SE2d 399) (2001).



                                           13
        4. Package inserts and user manuals do not, alone, establish the standard of

care.

        Wong argues that the “package inserts,” the documentation included with the

freezing tool used to perform the cryoablation, established the standard of care and

the trial court should have so instructed the jury. Similarly, he argues that Chappell’s

failure to follow the user manual included in this documentation amounted to simple

negligence.

        We hold that the package inserts are relevant to but do not conclusively

establish the standard of care. “A person professing to practice surgery or the

administering of medicine for compensation must bring to the exercise of his

profession a reasonable degree of care and skill. Any injury resulting from a want of

such care and skill shall be a tort for which a recovery may be had.” OCGA § 51-1-

27. “Such standard of care is that which, under similar conditions and like

circumstances, is ordinarily employed by the medical profession generally. . . .

Excepting in a few extreme circumstances, the question of compliance with the

required standards must be presented through expert testimony.” Kenney v. Piedmont

Hospital, 136 Ga. App. 660, 664 (3) (222 SE2d 162) (1975). “[T]he appropriate

medical standard is the province of the medical expert,” Morrison v. Koornick, 201

                                          14
Ga. App. 367, 370 (2) (411 SE2d 105) (1991), although documentary evidence can

be relevant to the issue. See Byrd v. Medical Center of Central Georgia, 258 Ga.

App. 286, 287-290 (1) (574 SE2d 326) (2002) (service manual used by hospital’s

surgical department was relevant to establish medical malpractice standard of care).

      To allow the package inserts alone to establish a physician’s standard of care

would be inconsistent with OCGA § 51-1-27 and our case law because it would

permit the manufacturer, rather than the medical profession, to establish the standard

of care. See Luckie v. Piggly-Wiggly Southern, 173 Ga. App. 177, 178 (1) (325 SE2d

844) (1984) (violation of privately-established rule does not, alone, show negligence).

Additionally, without expert assistance, a jury may not easily understand user

manuals, which are written for the medical profession, not the general public. Nor has

Wong presented any evidence that the manufacturer intended to establish the standard

of care when it prepared the materials. Moreover, the materials cannot be

cross-examined. For these reasons, we conclude that although relevant, the package

inserts alone do not establish the standard of care.

      Wong also argues that the failure to follow the package inserts was simple

negligence that did not require expert testimony. We disagree. As detailed in Division

2, supra, “[w]hether an action alleges professional malpractice or simple negligence

                                          15
depends on whether the professional’s alleged negligence required the exercise of

professional judgment and skill.” Peterson, supra, 243 Ga. App. at 754 (2) (citation

omitted). In any particular case, adhering to the manufacturer’s recommendations and

warnings may or may not have been within the standard of care when the alleged

negligent act occurred. Wong’s allegations of negligence in Chappell’s use of the

cryoablation tool challenge her professional judgment and skill and thus assert

professional negligence.

      The cases Wong cites for the proposition that failure to follow the written

directions is simple negligence are distinguishable. In Peterson, supra, at 755 (2), the

defendant had successfully moved to dismiss the plaintiff’s complaint for failure to

file an OCGA § 9-11-9.1 affidavit. We reversed as to one count of the complaint

because at that preliminary stage of the proceedings, we took the plaintiff’s

allegations as true, and it was at least arguable that she had asserted a claim of simple

negligence for which a § 9-11-9.1 affidavit was not needed. In Sood v. Smeigh, 259

Ga. App. 490 (578 SE2d 158) (2003), which is physical precedent only, we held that

the defendant’s act of assembling a prosthetic patella required only compliance with

the manufacturer’s instructions, not the exercise of professional discretion, so the

plaintiff’s action sounded in simple negligence. In Lamb v. Candler General Hosp.,

                                           16
262 Ga. 70, 71 (1) (413 SE2d 720) (1992), our Supreme Court held that “the failure

to replace disposable parts in the instrument involved in [that] case, as required for

its safe performance, create[d] an issue of simple negligence by hospital employees”

because, unlike here, professional skill and judgment were not involved. In Dent v.

Memorial Hosp., 270 Ga. 316 (509 SE2d 908) (1998), our Supreme Court held that

the plaintiffs’ allegations concerning nursing staff’s failure to activate the alarm on

a sleep apnea monitor – as the physician had instructed – asserted simple negligence

because such acts did not involve the exercise of professional judgment.

      5. Admission of May 2011 resource guide.

      Wong argues that the trial court erred by admitting a “resource guide” that was

not in effect at the time of Mrs. Wong’s procedure. He argues that the admission of

this document, which approved ten-minute freezes versus the earlier recommended,

four-to-six minute freezes, allowed the defendants to argue that a ten-minute freeze

was the standard of care.

      We agree with Wong that the applicable standard of care is the standard of care

at the time of the alleged negligent act. McDaniel v. Hendrix, 260 Ga. 857, 859 (1)

(401 SE2d 260) (1991) (relevant standard of care is the standard of care employed by

medical profession under similar conditions and like circumstances). But the trial

                                          17
court could have found that the later-published resource guide was relevant to the

standard of care at the time of Mrs. Wong’s procedure, because it demonstrated the

manufacturer’s revision of its guidelines to reflect the practice in the medical

community or information available at that earlier time.

      “‘[R]elevant evidence’ means evidence having any tendency to make the

existence of any fact that is of consequence to the determination of the action more

probable or less probable than it would be without the evidence.” OCGA § 24-4-

401.”[T[he admission of evidence is within the sound discretion of the trial court and

appellate courts will not interfere absent abuse of that discretion. . . . [N]o matter how

slight the probative value, our law favors admission of relevant evidence.” City of

Atlanta v. Bennett, 322 Ga. App. 726, 727-728 (1) (2013) (citations and punctuation

omitted). See also OCGA § 24-4-402 (generally, “[a]ll relevant evidence shall be

admissible. . . .”). Wong has not shown that the trial court abused her discretion in

admitting this evidence.

      6. Remaining enumerations of error.

      Given our reversal of the defense verdict, we do not address Wong’s argument

that the trial court erred in granting the defendants’ motion for a directed verdict on

his punitive damages claim. Whether the trial court again grants that motion will

                                           18
depend on the evidence presented at the retrial. Nor do we address Wong’s argument

that the trial court erred in allowing defense counsel to strike a juror for cause after

the parties had begun exercising their peremptory challenges, because any such error

is unlikely to recur.

      Judgment reversed and case remanded. Ellington, P. J., concurs; Dillard, J.,

concurs in the judgment only.




                                          19
