"If it's not in the medical records, it didn't happen."
This quotation is presented courtesy of a Senior Claims Adjuster
of a major insurance carrier. You cannot claim injuries or pain from
participating in activities if they are not documented in your medical
records. Your doctors are not interested in making your claim for you. It
is your job to manage your own medical records by giving them your
information. There is an excellent discussion of this in Medical Records.
Take written notes to the doctor's office. When you are asked how you are
feeling, you and the doctor can go over the notes together. Make it an
informal thing so it appears the notes were made to aid the doctor in
diagnosing and treating you. Hopefully, at least a third of what you have
written down will find its way into the medical records. If the doctor
wants to keep your notes, that's great. Just know they will be discoverable
if you go to trial, but they might really aid the doctor when you ask for a
Some other things to consider regarding your medical records:
- Be careful not to mention the claim process to the doctor or her staff
- Your phone messages taken down by the receptionist or nurse will end up
in your medical record, so be careful what you say.
- While letting the doctor know you have a positive attitude about
getting better, don't be afraid to bring in a list of pains since the last
visit, including any indication of activities which may have resulted in
pain - even if the pain does not occur until the next day or later after
participating in the activity.
- If you are not recovering and your doctor says she doesn't know what to
do, suggest a referral to a specialist who might have an alternate
- Consider a pain clinic.
- Communicate with all care providers on all symptoms.
Consider this example. You are going to your chiropractor for
treatment of your neck pain. You notice that your jaw has been clicking or
hurting, or you notice that your knee has been hurting or grinding. Do you
mention those topics when the chiropractor asks how your neck has been
feeling? The answer is, yes!
It is likely that your jaw or knee problem was caused by trauma. Maybe,
without realizing it, you banged your knee on the other side of the
steering column while pushing on the brake. Again, make the list in writing
and let her know about these problems. Some problems - especially with the
jaw -- don't show up until three to six months after an accident, and you
want them documented in the medical records immediately, not waiting until
a year after the accident when they've reached a serious pain or disability
If you are referred to a specialist and the diagnosis is TMJ or TMD, the
dentist may be able to trace the cause to the accident. But ,without any
annotations along the way in the medical records, it would be difficult to
prove that it was accident-related. That's where the chiropractor's notes
from the second or third month after the accident that you have had a
clicking or pain in your jaw would come in handy. Particularly if he
continues to note the progression of the problem and referral, you will
have demonstrated the causation link, and your medical costs and pain and
suffering should be compensated.
The insurance industry is saying is that your doctor's reports will govern
the value of your settlement award much more than your testimony or the
testimony of your family and friends. If you could not do something, if you
were feeling a pain in your shoulder, or if you have numbness or tingling
in your wrist or fingers, your medical records will have to have an early
mention of these problems or you will not fully recover the financial value
you would otherwise be entitled to for those injuries.
One of the biggest challenges in handling personal injury claims is the
inaccuracy and incompetence displayed in the medical records
of healthcare professionals. One would be amazed to see the comments of the
doctors in their records as compared to what the patient believes she told
the doctor or what the doctor told her. It is absolutely essential that
your healthcare professional have a full, accurate and honest history
of the problems you encountered before, during and after your accident.
Your history must include specific mention of any injuries related
to your present injuries that were suffered in recent years prior to this
claim. The insurance industry has it all on computer by this time and, if
you've ever been involved in any type of a claim before, that
claim will pop up.