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The Importance of Medical Documentation in Personal Injury Claims
It is almost impossible to overstate the importance of medical documentation in personal injury claims. From the first hospital visit after your accident through to the time of your final treatment session, each piece of evidence paints a picture of what you have endured. Thus, your medical treatment will help a personal injury attorney to work on your behalf, build a strong case, and pursue the compensation you deserve.
In this article, we will explore why medical documentation is so critical. We will also consider how to collect comprehensive medical documentation and how an experienced personal injury attorney may use it throughout the claims process.
Why Medical Documentation Matters
Every personal injury claim hinges on proving – among other things – that your accident was the direct cause of your injuries. Proper medical documentation makes it possible to prove this causation. Once the link has been established, the seriousness of your injuries can then be considered.
Although the goal of personal injury claims is to avoid going to court, they still have the legal framework similar to that of a lawsuit.
To build a strong personal injury claim, an attorney must establish the following:
- Duty of care: The negligent party must have breached his or her duty of care toward you
- Breach of duty of care: By his or her negligent actions or inactions, he or she breached the duty of care
- Cause: The breach was the direct cause of your injuries; medical documentation may provide objective evidence to prove this point
- Compensation: The injuries you sustained caused financial losses, for which you are entitled to compensation; again, medical records can provide crucial evidence to show the impact of your injuries on your life
A personal injury claim would not be viable without medical documentation to establish cause and compensation.
How Medical Records Establish Cause
Whether you were injured in a car accident, a slip-and-fall accident, were hurt at work, or had other circumstances that led to your injury, the onus is on you to prove that your accident caused your injuries. Medical documentation can help prove the accident caused your issues and that you did not have these problems before.
Expert witness testimony
Your personal injury attorney is not a medical expert. However, he or she can call upon qualified expert witnesses with experience in the medical field to review relevant medical documentation and determine the cause of your injuries. Their testimonies could be valuable when establishing liability and fighting for your rights.
Nullify the pre-existing conditions defense
A common tactic among insurance adjusters is to claim that your injuries were not caused by your accident. They may try to argue that your condition was pre-existing or contributed to your accident in some way.
An objective review of your medical records from prior to and after the accident could strengthen your case. It could prove that you did not have these injuries before and that your state of health did not put you at greater risk of being involved in an accident.
Medical Documentation and Fair Compensation
Your personal injury attorney must prove that the compensation you are seeking is reasonable for the injuries you sustained. Medical documentation is one primary way to prove your injury claims.
In New York personal injury claims, you can pursue two types of compensation:
- Economic losses: Actual expenses, such as hospital bills, tests, medications, therapies, and lost earnings due to your injuries
- Non-economic losses: Intangible losses that could include pain and suffering, disfigurement, or loss of enjoyment of family life
Calculating economic compensation
Keeping detailed records of all medical expenses will help your attorney calculate the actual cost of your medical treatment and lost earnings to date. This information can also be used to predict your long-term medical expenses if you have a long-term condition.
For example, if you sustained a severe traumatic brain injury (TBI), you may have required extensive treatment over a long period of time. This could have included an extended hospital stay followed by intensive rehabilitation.
You may have finally reached maximum medical improvement but still require caretaker support. Naturally, you will have lost earnings along the way and may be unable to return to the work you did before.
Comprehensive medical records help build a clear picture of the accident’s impact on your life. Rehabilitation records may demonstrate the tasks you can perform independently and those with which you continue to require assistance.
Medical experts can use these records to make a long-term prognosis and estimate the medical care you will need in the future. This testimony allows your attorney to calculate the cost of future care and lost earnings.
Calculating non-economic compensation
Medical records are also crucial for calculating non-economic compensation. These records allow your attorney to create a treatment timeline.
Medical records not only show the cost of your treatment at every stage but can also speak to the extent of your suffering. You may be able to add weight to this by keeping a personal injury journal detailing your suffering each day.
Attorneys and insurance companies often use the multiplier method in personal injury claims involving serious injuries. This involves multiplying your economic losses by a certain number to obtain a figure for non-economic compensation. For less serious injuries, the figure may be closer to 1, whereas more serious injuries may multiply the losses by as much as 5 times the economic loss figure.
It is clear that, without detailed medical records, you would face an uphill legal battle to prove you are entitled to the compensation you need. However, ensuring the existence of solid medical records makes it much easier for a personal injury attorney to calculate fair compensation and fight tenaciously to try to secure it.
Medical Documentation: What You Need
Relevant medical documentation that can support a personal injury claim includes evidence from both and after your accident. It could include the following and more.
Your attorney and the insurance company may request your medical records from before your accident. The goal is to understand your state of health before the accident.
Medical records include details regarding:
- Prescription medications
- General notes from your main healthcare provider
Emergency room records
If you were seriously injured and required immediate medical attention in the emergency room, these notes can testify to your condition right after the accident.
Diagnostic tests and results
Collect all lab reports, X-rays, MRIs, CT scans, and the results of other diagnostic procedures. These can paint a clear picture of the immediate impact of the accident and show why further treatment was necessary.
Your treatment notes should include a detailed description of the injuries you sustained and the treatment plan put in place. The notes will provide a chronological account of your recovery.
Treatment notes could be crucial in establishing causation and strengthening your claim for non-economic damages.
Other medical evidence
Serious injuries often require extensive rehabilitation. Notes from physical therapy and other treatment sessions can provide valuable insights into your recovery and the likely long-term impact of your injuries.
Collectively, these medical records should provide a detailed account of your injuries from the time of your accident until reaching maximum medical improvement. However, mistakes in medical records could create challenges when seeking compensation.
Common Issues With Medical Documentation
We would all expect healthcare providers to keep meticulous records. Sadly, in reality, this does not always happen. Missing records and other mistakes could make it harder for you to prove how your injuries have impacted your life.
From the start of your treatment, it is important to keep track of your medical documentation to avoid the following issues:
- Lack of detail: What if the doctor or other healthcare provider’s notes are incomplete or ambiguous? The opposing parties could pounce on this to contend that your injuries are not as serious as you claim.
- Delay in releasing records: This can cause gaps in the medical narrative, creating doubts about the accuracy of the records.
- Inconsistencies: Conflicting information from different healthcare providers could weaken your case.
- Not documenting pre-existing conditions: Pre-existing conditions may not have caused your accident, but it may have made them worse. Failing to document this impact could make building a strong personal injury case harder.
Gathering the Medical Documentation You Need
Collecting medical evidence requires diligence and consistency. The following steps can help you keep track of everything you need:
- Request copies of all previous medical records
- Keep a diary of all medical appointments, including details of what happened at each appointment
- Maintain a single file in chronological order with all of your medical documentation
- Consider creating a summary that outlines the key information from each document
- Create digital copies of all medical documentation to make finding and sharing documents easier
Legal professionals may be able to assist with this process. However, the more medical documentation you can provide, the faster they may be able to build your case and begin negotiations.
Seek Justice With Hill & Moin
Proper medical documentation can make a huge difference in your personal injury claim. With detailed medical records, an experienced personal injury attorney can build a complete picture of your injuries. He or she will be able to calculate a fair settlement and fight hard in pursuit of the compensation you need to rebuild your life.
Working with the legal team at Hill & Moin is like having a lawyer in the family. We care about getting justice for our clients and use all our resources to fight tenaciously for their rights. This determination has allowed us to secure seven-figure settlements for many clients.
Now is the time to discover what our experienced and compassionate attorneys can do for you. Call (212) 668-6000 today to learn about your Personal Injury Recovery SolutionsⓇ.
Don’t wonder about your rights!