Medical Documentation in Accident Cases – Key Aspects Involved

Reports from the Association for Safe International Travel (ASIRT) say that about 4.4 million people get seriously injured in US roadway accidents and require serious medical attention. These accidents lead to personal injury cases that may be eligible for compensation if the injury occurred due to someone else’s negligence. To file a claim for an accident or injury caused by another person’s negligent actions, the injured victim must be able to provide evidence that his/her injuries were directly caused by the other party’s actions. Proper documentation of injuries and evidence of damages are vital to win an accident lawsuit and get eligible compensation. Personal injury attorneys have to collect relevant medical records from claimants that would provide important evidence to support their argument in a court of law. Medical review services help attorneys analyze, interpret, organize and summarize voluminous medical records.

Importance of Medical Documentation in Accident Cases

In simple terms, medical documentation encompasses every medical record from the initial physician’s visit to the final treatment session. Medical documentation is important in a personal injury case for different reasons–

• Firstly, it clearly establishes the existence of an injury as well as its type, severity and cause. Proper documentation provides a solid foundation for an accident case wherein it can be clearly proved that the accident was caused by the defendant or the defendant's negligence directly led to the claimant’s injuries.
• Secondly, it can help prove that a claimant had no health complaints relating to the injury prior to the accident. It can also help claimants who did have a pre-existing condition establish that the injuries are new or stemming from the accident.
• Proper documentation helps determine an appropriate compensation including both economic and non-economic damages (such as mental anguish or chronic pain).

The more medical documentation a personal injury attorney can gather, the better will be the chances to formulate an amount that adequately reimburses the claimant for the injuries and pain suffered. Having these records handy will help the legal team understand the claimant’s medical history and confidently proceed with the case.

Types of Medical Records Required for Accident Claims

The basic purpose of medical records is to establish a clear picture of an injured person’s health journey. Medical records from emergency responders, hospital, physical therapists, psychologists, and all other medical professionals and healthcare providers who provided medical care soon after the accident have to be obtained.

As every case is different, the types of evidence required will also vary. Evidence may include diverse documents showing proof of the accident – police reports, witness statements or photos of the injuries, medical bills and records (prescriptions, treatments received, receipts and discharge information), testimony, and loss of income estimates. These documents or evidence will help demonstrate the severity of injuries and make a connection to the accident. Here listed are the medical records that personal injury attorneys would need to develop the case –

• Photographs of the Accident Scene and Injuries - One of the best ways to document evidence, photographs serve as an important visual representation of the type and severity of injuries, the accident scene and damage to property. These also play an important role in putting together the details of what caused the accident. If possible, victims can consider clicking pictures of their own injuries, the damage sustained by the vehicle in multiple angles, and the location where the accident took place. Such images can help attorneys prove the opponent’s negligence. In short, make sure to document as much as possible, even if the injury or damage is small.
• Medical Records from first responders and hospital records - Medical documents from emergency responders, hospitals, physical therapists, psychologists, and other medical professionals and healthcare providers who provided medical care after the accident.

 Initial treatment report

 Medical bills and prescriptions

 Physician reports

 Medical test results

 Copies of medical imaging results, and other relevant details

 Receipts and discharge information

It is also important to request medical records from before the accident from the claimant’s primary care physician to show how healthy the claimant was before the injuries. It is important to save copies of questionnaires, benefit letters, and other documentation received from the insurance company. Immediate medical treatment and related reports help attorneys prove that the claimant’s injury was directly caused by the accident.

• Copies of the Accident Report – Accident reports and police reports are fundamental for providing an objective and professional perspective on what caused the accident.
• Witness Statements - Witness statements serve as key evidence in an accident case. Soon after an accident, it is always best to collect the contact information including – names, phone numbers, home addresses, and email ids -- of people who witnessed the accident. Also, take note of the key points they remember about the accident. Attorneys can utilize such information to build an accurate interpretation of the events that occurred before and during the accident.

• Communication Records – Maintain detailed records of all conversations that a claimant had with the insurance company about the accident and injuries. Email is the best way to ensure transparent and accurate communication.

• Documentation of Lost Wages – In many cases, a serious injury will prevent an individual from returning to work, either for a short period of time or indefinitely. To prove that a person lost wages due to the injuries, a note must be obtained from the treating physician detailing the specific dates on which the injured person was unable to work because of the injuries. Evidence related to pre-accident earnings is necessary to determine exactly how much pay was lost due to the injuries.

• Insurance Policy - Personal injury attorneys can review the details of the policy with the injured person to determine what is and is not covered.

• Daily Journal about the Changes after the Accident – Pain and suffering can have a significant impact on a person’s life after an accident and these cannot be quantified as other types of injuries. Therefore, the injured person needs to maintain a daily journal wherein they can note down the type and amount of pain and suffering they experienced and how the injuries and medical treatment had affected their life. Also, any mental issues such as stress, sleeplessness, anxiety, or confusion experienced in the course of the treatment must also be documented. Such notes can be used to prove non-economic damages resulting from another party’s negligence.

When it comes to medical documentation, all relevant medical records relating to the case are essential to prove that the injury or incident occurred due to another party’s negligence. Personal injury attorneys may request the claimant to summarize the events surrounding the accident in their own words. By collecting all relevant evidence and documents related to the incident, an accurate timeline can be created of the accident and its repercussions. Proper medical records organization is another support solution available for law firms and attorneys handling personal injury lawsuits. Professional medical review companies can provide a thorough analysis of the medical records and identify all key elements contributing to the injury.

Disclaimer: This content is for informative purposes only and does not constitute professional legal advice. For a professional opinion, consult a personal injury attorney.