The Importance of Medical Documentation in Proving Your Case

It doesn’t matter if you’re injured in a car crash, slip and fall, dog attack, or other type of accident—every type of personal injury claim hinges on evidence. The more evidence you have to prove that the other party caused your injuries and that your injuries are serious enough to warrant compensation, the stronger your case may be. Without sufficient medical documentation, you’ll run into issues when it comes to negotiating fair compensation with an insurance company.

That’s where our team of personal injury attorneys steps in to help. We know what it takes to prove your case to demanding insurance adjusters. Call Santoro & Gray to set up a consultation right away.

How medical documentation establishes causation

A big part of having medical documentation is using it to prove that the accident caused your injuries, which is a critical component of proving your claim. You don’t just need to prove that you’re injured; you need to show that those injuries were the result of the accident. For example, if you are involved in a car accident, a doctor’s diagnosis of whiplash and a concussion can prove that the other party rear-ending you is what injured you.

The easiest way to prove causation is to seek medical attention as soon as possible after an accident. The less time there is between an accident and your medical checkup, the harder it is for insurance companies to claim that some other mysterious factor injured you.

Medical records that validate injury severity

Demonstrating injury severity is essential if you want fair compensation for your losses. Let’s say that the insurance company believes that your injury was caused by their client’s actions, but they believe that the injuries are so minor that no compensation is necessary. If you can, then provide proof that your injuries have limited your mobility, require ongoing pain management via medication, and have taken you out of work for weeks on end; it is much harder for them to make that claim. Progress notes and notes from each doctor’s appointment can track your pain levels, ability to function normally, and lost mobility.

Specialist reports may be useful when it comes to proving injury severity. Strength testing, functional capacity evaluations, and range-of-motion measurements are just a few ways that specialists may track the development of your injuries over time.

Ideally, your reports of pain and limited mobility will be backed up with objective tests. While it’s impossible to objectively measure pain, diagnostic tests can show conditions that are known to cause pain, such as bulging discs, torn muscles, and pinched nerves.

How medical records can affect settlement value

The quality and depth of your medical documentation play a clear role in how much you’re ultimately offered by the at-fault party’s insurance company. Insurance adjusters don’t base settlement offers on what victims say. They look at how little they can offer without risking a time-consuming and expensive lawsuit. A claim of serious injuries with minimal or no medical documentation is no great risk to an insurance company, because they know a jury is unlikely to award significant damages without strong medical evidence, even if it finds the defendant liable. But if you have months’ worth of treatment records, progress notes from doctors in various specialties, and proof of limited progress via physical therapy and diagnostic scans, the risk of them being found liable in court is much, much higher.

Not only do your records prove the severity of your injuries and the validity of the medical bills you want paid, but they can also determine how much compensation you receive for pain and suffering. This makes up a significant portion of your non-economic damages, and having evidence for your pain levels can be very helpful.

Finally, if you are catastrophically injured, you need compensation for future medical care if you want your settlement to truly be fair. Medical records play a big role in you getting that compensation. Your medical documentation may show that you have permanent deficits caused by your injuries and outline what type of care you are likely to need as you look to the future.

The importance of consistent treatment

Consistent treatment is a crucial part of your recovery. If you skip appointments, frequently reschedule appointments, or fail to do your physical therapy exercises between appointments, that shows the insurance company that you aren’t taking your injury seriously. Gaps in treatment cause serious harm to your claim, because the insurance company won’t want to pay compensation for injuries you seem uninterested in recovering from.

Documentation issues that can hurt your claim

Avoid these mistakes if you want to support your personal injury claim and prevent battles with the insurance company:

• Not mentioning all of your symptoms right away: If new symptoms suddenly appear in your medical documentation weeks after your initial injury, insurance companies may wonder if you’re angling for extra compensation. While new symptoms can appear sometimes, it’s more common that victims just forget to describe all of their symptoms to their care provider from the very beginning.
• Downplaying your pain: It is so common for victims to downplay their pain levels when they seek medical care. It can feel embarrassing to be honest about severe pain, especially when society applauds those who soldier through and tough it out. This isn’t the time to put on a brave face; it’s the time to be brutally honest with your care providers.
• Changing your story over time: If your description of your injury isn’t consistent across appointments, you can expect your doctor to include it in their notes—and insurance will likely use it against you.
• Ignoring specialist referrals: After an injury, you have to be fully invested in recovering, which means following up on any resources provided to you. If your medical records show that your care provider gave you specialist referrals and you never followed up on them, that could devalue your claim.

Discuss your options with the team at Santoro & Gray

If you’ve been injured because of another person’s recklessness or negligence, we’re here to help you hold them accountable. You can call us today or reach us by text, live chat, or our online contact form.