The Importance of Medical Records and Talking About All of Your Injuries to Your Doctor


doctor filling in medical records on a laptop

You Need to Tell Your Doctor About ALL of Your Injuries

I have had clients tell me in the past that their doctor told them when they started treatment that the doctor did not need to hear about injuries other than the worst injuries and any other injuries would be addressed at a later time after dealing with what the doctor considers to be the main injury. This is absolutely wrong on the doctor’s part and you need to keep addressing every injury at every appointment, especially with the primary care doctor (this is usually the doctor that is making referrals to other professionals to treat your injuries, but could include other doctors as well). The reason for this is that when you go to your doctor, they document what they discussed with you at the appointment during all follow up appointments. When they create their records, they usually only document the issues discussed and do not bring up other issues. So when your doctor tells you that they just want to deal with your major injuries and other issues can be addressed later, you just need to know that they usually don’t note in their documentation that they told you to bring those other issues up later. They just document the primary injuries they talked to you about.

This Can Affect Your Claim

So here is the problem when your doctor does this. The doctor makes the record and eventually we pull those records to gather documentation of your claim to provide to the insurance company in support of our demand. When there is no mention in the records of other pains or physical conditions which arose as a result of the accident it becomes very difficult for us to explain how the injuries from the accident affected you. When the adjuster eventually gets the records and our demand, they will start looking for documentation of the injuries to all of the areas we are claiming in our demand. If there is no mention of a particular injury, such as a knee injury from hitting the dash (very common), the adjuster will indicate that because there are no records pertaining to that injury, it must not have happened, or if it did, you must have made a full recovery and no compensation is necessary.

Just as bad is that your doctor will likely forget that you had other physical problems and they often end up never addressing them, or if they do, the record reflects that you started complaining about the injury months, or more, later. When this happens, the adjuster will take the position that it is not related to the original injury and then it is just an unnecessary fight to get you compensation.

Make Sure Your Doctors are Documenting Everything

So when you see your primary care doctor, and likely other medical professionals, make sure that you address all injuries that you sustained from the incident at each appointment and keep bringing them up. If the doctor tells you that they will address that later, make sure to ask that they document that in the records as well. Then you want to make sure that you bring the issue up again at the next appointment (sometimes it can be beneficial to make an injury list just so you don’t forget). It will make things easier for you in the future and might help you to settle your claim and avoid the stress of having to file a lawsuit.

If you need help with a personal injury claim, call us at 719-633-6620.