"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. Members onlyMembers only 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 Narrative Letter.
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 treatment plan.
  • 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 level.
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.