What Medical Documentation Do You Need for a Successful Personal Injury Claim?

Proper documentation is key to a successful claim. Working with an experienced personal injury attorney can help.

A successful personal injury claim hinges on proving the existence, cause, and severity of a victim's injuries. If you've recently been involved in an accident and are seeking compensation for the injuries you've incurred, medical documentation can make or break your case. Before you and your personal injury attorney serve a defendant with a demand letter, these are the documents you'll need to fight your case.

Why Is Medical Documentation Important?

Medical documentation encompasses every medical correspondence from your initial doctor's visit to your last treatment session. Therefore, there is a lot of evidence which falls under this umbrella. Medical documentation is critical to a personal injury case for three reasons.

Medical documentation establishes the existence of an injury as well as its type, severity, and cause. Proper documentation provides a solid foundation for your case in which you can prove that the accident caused by the defendant or the defendant's negligence directly led to your injuries.

Medical documentation can prove that a plaintiff had no prior health complaints relating to the injury prior to the accident. On the other hand, it can also help plaintiffs who did have a pre-existing condition establish that the injuries are new or stemming from the accident.

Medical documentation helps determine an appropriate settlement or judgment amount, including both economic and non-economic damages, such as mental anguish or chronic pain.

The more medical documentation you and your attorney can gather, the better. When quantifying non-economic losses, which do not have a billed monetary amount, your attorney will need to utilize medical records and prognosis to formulate an amount which adequately reimburses you for your pain.

Likewise, an experienced personal injury attorney will utilize these medical records as leverage against insurance companies, who will likely attempt to offer you a lesser amount than you are owed for your injuries.

What You Need: Medical Records

The purpose of medical records is to establish a picture of your health journey. Following an accident, the first step you should take is to visit a qualified medical professional to examine any injuries. This can be the emergency room or your general practitioner, whichever doctor you can get to the fastest to ensure your health and safety.

Medical records play a large role in establishing causation in a personal injury claim. These documents include:

- Doctor's diagnosis
- Line-item medical bills
- Detailed notes from doctor's appointments

These documents will not only list the doctor's diagnosis of the injury, but also therapy plans and prescriptions for your current condition, and substantiate that your injuries manifested as a result of the accident. Bear in mind that when gathering medical records, anything and everything that relates to the case can and should be included. Therefore, you and your attorney should be one step ahead.

For instance, if you suffered a bone fracture as a result of an accident, provide all related documentation. If you had x-rays taken, provide records from your doctor as well as your radiologist. Medical records from any physicians, therapists, specialists, or hospitals are necessary to serve as hard evidence.

While this might seem repetitive, coming equipped with the most solid evidence increases your likelihood of arguing a successful claim.

Medical Bills: A Line by Line Breakdown

To begin calculating a rough estimate of a personal injury claim, compile all resulting medical bills. It is crucial you share all of this information with your personal injury attorney, and allow him or her to help you with this process. When compiling medical bills, include every service or therapy used in your treatment.

Bills that should be included (if applicable) include:

- Surgery costs
- Ambulance fees
- Blood work or scans
- Doctor appointments
- Physical rehabilitation
- Prescription medication
- Diagnostic imaging, such as x-rays or CT scans

While you are at the doctor's office or hospital, ask for a breakdown of the cost of your treatment. This is known as a line-item medical bill, and as its name suggests, it will allocate each service listed in the bill to a specific price.

Log All Out-of-Pocket Expenses

Suffering an injury often means several trips back and forth to the doctor's office, medicine, and requests for medical records. These financial burdens are known as out-of-pocket expenses, and they're often items that a victim will be forced to pay for throughout the entirety of a claim.

These items should be included within your medical documentation. Any expenses or receipts related to the injury must be noted, including

- Medicine
- Medical supplies
- Healthcare services
- Requests for medical records

With the help of a knowledgeable South Florida personal injury attorney, these expenses can be itemized and included in a claim.

Photograph Noted Injuries

In personal injury cases, both yourself and your attorney will want to come equipped with as much evidence as possible. If you've recently suffered an injury, it is wise to photograph all noted injuries listed in your claim. Begin documenting the injury as soon as possible, and document its healing throughout stages of your treatment.

From broken bones to bruising, having a photographic record of damages not only confirms that injuries do exist, but also plays in your favor if your trial is ultimately heard in front of a jury. Additionally, keep track of your injury treatment in a personal injury journal. Make note of:

- How you're feeling
- What treatment you're undergoing
- What physical symptoms you're experiencing
- Emotional and mental symptoms you're experiencing
- What doctor/specialist appointment you attended that day

Remember, not all damages will be broken up into dollar amounts on your personal injury claim. You'll also have non-economic damages which aim to compensate you for the mental anguish and chronic pain you're experiencing. Keeping a written and photographed log of your personal injury journey helps to establish these charges.

Building a Successful Case

When it comes to medical documentation, leave no paper trail left untraveled. Medical records including bills and photographs help to establish a case that the defense will have a hard time arguing.

However, do be alert that, after you provide all of the above information, the defense may still call for additional medical records. Some insurance adjusters or opposing attorneys will request medical records for the pure purpose of snooping to find evidence they can use against you. If the request for additional medical records seems unreasonable or unrelated to the injuries suffered in the accident, direct them to your attorney.

Together with the help of a personal injury attorney, compiling all necessary medical documentation will help build you a successful personal injury claim.

ABOUT THE AUTHOR: Justin Weinstein
Justin Weinstein is a personal injury attorney and founder of Weinstein Legal, a Fort Lauderdale law firm. The Weinstein Legal team provides personal attention and legal representation in claims for motor vehicle accidents, slip and fall accidents, wrongful death, and more.

Copyright Weinstein Legal

Disclaimer: Every effort has been made to ensure the accuracy of this publication at the time it was written. It is not intended to provide legal advice or suggest a guaranteed outcome as individual situations will differ and the law may have changed since publication. Readers considering legal action should consult with an experienced lawyer to understand current laws and.how they may affect a case. For specific technical or legal advice on the information provided and related topics, please contact the author.

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