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Part 2 – Building a Better Medical Record for Your Catastrophic Injury Lawsuit

Medical records

In a previous post we began the discussion of how to ensure your medical record helps you following a catastrophic injury (as opposed to hurting your chances of recovering compensation). When presented to a judge or jury, your medical record should “tell the story” of how your injury was inflicted and what steps you undertook to obtain restoration and healing. In order to accomplish this, your record should show:

The results of any images or testing that was performed. It is not as uncommon as one might think for an injury victim’s medical record to contain notations suggesting that imaging (such as X-rays) was ordered or tests performed but not contain copies of the imaging or the results of the tests. When presented with such an incomplete medical record, judges and juries will usually assume that there are no images or test results.
Statements from specialists. If your injuries require you to visit with a specialist for treatment, judges and juries typically expect that notes and reports from these specialists will appear in your medical records. While some primary treating physicians will refer to observations and conclusions made by specialists, judges and juries like to see the actual reports made by these specialists to which your primary treating physician refers.
You followed “doctor’s orders.” In addition to returning for follow-up visits when told to do so, you will want to follow your doctor’s at-home treatment directions. If the doctor prescribes you medication, you should fill that medication and take it as prescribed until your doctor tells you that you no longer need it. When your doctor changes your treatment protocol (i.e., prescribes you a different medication or orders a different type of rehabilitative treatment), be sure that the medical record shows you complied. Ideally, your medical record will contain verification from pharmacies and other medical service providers that your doctor’s orders were complied with.

Your Medical Record is Your Responsibility

It falls to you, the injury victim, to make sure your medical record is complete and ready to be submitted and scrutinized as part of your personal injury case. Sometimes, though, tracking down all the medical professionals who were involved in your personal injury case can be challenging. Not only this, but some may demand you pay extremely high coping fees before releasing your records to you. While you can undertake the challenge of assembling your own medical records, having the experienced assistance of a personal injury law firm can alleviate the stress and uncertainty associated with assembling your medical records.

The Riverside personal injury law firm of Heiting & Irwin are available to assist personal injury victims who experienced injuries and losses because of another person’s careless behavior. We work with our clients to prepare and present compelling and persuasive claims for damages. Contact us at (951) 682-6400 or write to us online to start the recovery process.

Click HERE to read part 1 of “Building a Better Medical Record for Your Injury Lawsuit”.

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Mr. Serrano has been admitted to practice before California State and Federal Courts. He was named to the Super Lawyers’ 2012, 2013, 2014, 2015, and 2016 Southern California Rising Stars List, an honor awarded to no more than 2.5% of attorneys in Southern California each year. View Attorney Jean-Simon Serrano's Attorney Bio Here.

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