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Medical Records are Important in all Injury and Disability Cases

On Behalf of | May 16, 2011 | Civil Trial, Legally Speaking, Personal Injury, Workers' Compensation

Every court assumes a patient will always tell their doctor the truth. They also assume this truth is fully and accurately reported in the medical records. No matter what type of case you have, personal injury, social security or workers’ compensation; your medical records are key to your recovery. Therefore, what medical records say or do not say speaks loudly in every courtroom. You should always be honest with your doctor and also explicit as to all of the issues or problems you are having, not just the day of the visit; but everything that has happened since your last visit. Why is it so important to give your physicians so much back ground and information on your condition? First, because that will help the doctor help you with your medical condition, diagnosis or injury. Second, because it will help the court, judge or jury understand what your medical problems really are from the records. Tell your doctor everything that is going on every time and be honest about what your real problems are at that time. You should not use general words like good, fine or okay unless that is exactly what you mean. If those words appear in your medical records, it will look like you are not having any problems.   People use these words loosely with their doctors when they mean nothing has changed. The doctor’s may understand this but it will not read that way in the records.   Remember, legally you will have to explain your own medical condition in your own words.  If your interpretation of your medical condition is vastly different from your doctors, you loose credibility as your word about your condition is not very strong in the eyes of others. Next, do not assume that any symptoms you have are unrelated or unimportant. You should tell your doctor everything so they have all of the information necessary to help treat and diagnose you. It will also help the court understand how long certain problems have been going on. Lastly, the court will assume if you did not tell your doctor, it must not have been a problem. Many patients only tell their doctors what caused them to be there that day or what has bothered them most recently.  You also have to tell them about how you felt in the days leading up to being seen as well.  If you don’t, the doctor cannot remember days or weeks later you were having the problem and he or she cannot then accurately convey to others what you have experienced. Remember, honesty is the best policy.


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