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Medical records for personal injury cases are comprehensive documents that contain detailed information about an individual’s injuries, medical history, and the treatment received following an accident or incident. These records are crucial evidence in personal injury claims and lawsuits. 

What details should be included in Medical Records?

Medical records will include things like basic personal details of the injured party such as name, address, date of birth, and contact information. They will also include an overview of the individual’s pre-existing medical conditions, prior injuries, and any relevant health information that may impact the current injuries. Medical records should be detailed and a description of how the injuries occurred, information about the accident, dates and times, and any immediate actions taken (such as emergency medical treatment). Other details that are included in good medical records for your personal injury case include but are not limited to: 

  • Clinical assessments: documentation of initial assessments such as observations, vital signs, and initial impressions of injuries. 
  • Diagnosis – any specific diagnoses related to the injuries sustained, supported by medical tests, imaging studies, and other diagnostic tools.
  • Treatment plans – details of the recommended treatment plan including surgeries, medications, physical therapy, rehabilitation, and any other interventions prescribed by healthcare providers.
  • Progress notes – ongoing notes that document progress during the course of treatment. This includes updates on recovery, changes in symptoms, and adjustments to the treatment plan. 
  • Medication records – a record of medications prescribed, dosage, frequency, and duration of use. 
  • Medical imaging – Results of x-rays, MRIs, CT scans or other diagnostic tests that provide visual evidence of injuries.
  • Lab results
  • Consultations and referrals 
  • Prognosis – healthcare providers’ opinions on the expected outcomes of the injuries, including any long-term effects or disabilities. This is something you may need to request but is very important.
  • Pain and suffering documentation – this includes descriptions of the individual’s pain levels, emotional distress, and any psychological impact resulting from injuries. 
  • Follow-up care – recommendations for ongoing care, follow-up appointments, and any future medical interventions that may be necessary. NOTE: It is important to actually go to these follow up care appointments.
  • Expert opinions – opinions and assessments from medical experts providing their professional perspective on the injuries and their impact. 

How Medical Records are linked to your personal injury case

Medical records play a crucial role in personal injury cases as they provide essential documentation that strongly assist in validating your personal injury case. They help to establish causation and are a direct link between the accident or incident and the incident claimed by the individual. Medical records provide evidence that the injuries were a result of the specific incident in question. This is crucial in determining the severity of the injuries, which can impact the amount of compensation sought in a personal injury claim. Treatment history, timeline of recovery, and proper documentation can all be used to demonstrate the impact of the injuries on the individual’s daily life and ability to work. Expert opinions and assessments from healthcare professionals carry significant weight in court. Well documented and properly authenticated medical records can typically be admissible as evidence inside the courtroom which will carry weight in your claim of personal injury.

How to Obtain and Organize Your Medical Records

Not all medical records are created equal! Obtain medical records from each medical professional you come into contact with along the journey of your treatment and recovery. There may be a series of steps involved to ensure you gather comprehensive and relevant information. Notify each health care provider who provides treatment that you would like to have a detailed copy of diagnosis, scans, their recommendations, expert opinions, treatment plan, medications prescribed, etc. included with the post op paperwork that you leave the office with. While this will not be an official medical record, it will help you keep everything well organized and may still prove to be valuable in the event you have any issues obtaining proper medical records. 

Below are some general steps in obtaining medical records for your personal injury law case. Your personal injury attorney will assist in this process. The earlier you hire a personal injury attorney in this process the better. 

  • Authorization from the injured party. You must provide written consent for the release of medical records. This can be done by contacting your healthcare provider and filling out a release form they provide. 
  • Contact healthcare providers. Reach out to each identified healthcare provider to request the medical records. This can be done by submitting the signed authorization form along with any required fees for copying and processing. This is where your personal organization becomes helpful as you will have a list of everyone you have seen and receiving treatment from and for what. 
  • Specify relevant time periods – clearly specify the time frame for which medical records are needed. 
  • Follow legal requirements. Be aware of and comply with any legal requirements for obtaining medical records. There may be specific rules and regulations for your jurisdiction regarding the release of medical information. Failure to adhere to these requirements could lead to delays. 

Some other important things to note are to keep copies of police reports, incident reports, or any other relevant documents that support the need for medical records. Keeping a record of all communications can be valuable in case any issues arise during the process. Follow up with healthcare providers to check on statuses of your requests and politely inquire about any delays and their reasons to seek and resolve any issues promptly. Lastly, review your records carefully for accuracy and completeness. 

In summary, medical records are essential in personal injury cases as they provide a factual and chronological account of the injuries, treatments, and impact on the individual’s life. They serve as a foundation for building a strong case and seeking appropriate compensation for damages. This can be a tedious and extensive process but your personal injury attorney is here to help! Contact Carmen at Liriano Law with any questions you may have or for your free personal injury law case consultation today.