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Car Accidents

Medical Records, Paperwork & Personal Injury: Be Specific


Did I Really Write That?; Did I Really Say That?

One of the biggest components of any personal injury claim is the treatment our clients undergo in order to be restored to pre-crash condition. Treatment can often be a long, tiring process. Part of that process includes office visits, imaging and even physical therapy. While many clients are dealing with those big ticket items, some clients overlook the importance of the questionnaires and paperwork they are given at each visit with a medical provider.

Completing Your Paperwork:

We are all guilty of just scanning paperwork and filling it out as quickly as possible thinking the doctor will come see us much faster if we do so. The problem is, however, that the medical paperwork and records filled out at each visit are critical to the evaluation and settlement of a personal injury claim. Why? Because you can trust that the insurance adjusters who will decide whether to pay your claim will read every word of those records. And the adjusters are reading those records looking for reasons not to pay you.

The importance of the medical records and paperwork you fill out at each doctor’s visit cannot be understated. If you are treating for a car crash, it is paramount that you carefully read each questionnaire or record, and answer each question truthfully, and with specificity. If the questionnaire asks you to rate the pain level you are experiencing that day, and you are not in much pain that day, it is reasonable to state that your pain level is a 2 or 3 that day. If on the next visit, your pain level is a 7 or 8, then you must indicate that as well. That is the ebb and flow of life; sometimes you feel ok, but other times you feel worse.

The worst thing you can do is simply avoid the question or exaggerate your pain levels or condition. The insurance adjusters will read every single record. If you indicate that you are a 10 pain level at each visit, and you are treating for a soft-tissue injury without any objective findings, it is unlikely that the carriers will take your claim seriously.

Reporting Your Injuries:

The same is true when you are reporting your injuries to the treating physician or emergency room doctor. Let’s focus on the emergency room doctor, first. If you are involved in a wreck, you should always go to the emergency room so you can be evaluated as a precaution. When you arrive at the emergency room, you should always report to the treating ER physician that you were involved in a car crash and you are concerned about potential injury. If you fail to inform the treating physician about the wreck or provide specific examples of the actual pain you are experiencing, you can anticipate that the ER doctor will send you on your way and tell you to see your primary physician.

If you are specific about the issues or pain you are experiencing, such as a headache, numbness, burning pain, etc., then you can expect a much more thorough examination, and a diagnosis that will turn up in the medical records related to your visit.

The same specificity is necessary when you visit an orthopedist for your injuries. If you are experiencing some type of back or neck pain as a result of the car crash, then it is best that you describe that pain to the treating physician, and be as specific as possible. Simply stating that your back hurts or you feel pain is not enough for the treating physician to accurately diagnose your injuries.

Typically you only get 5-10 minutes with a doctor (after waiting sometimes for over an hour). If you describe your injuries with specificity, the treating physician will have the ability to accurately diagnose you and dictate your medical records. Moreover, the record that is later produced will become part of your claim, and the adjuster handling your claim will have a more difficult time rebutting your injuries.

Your records, diagnosis, and treatment will all have a final impact on whether you can obtain a settlement for your injuries. Therefore, you must be mindful that everything you say or write will become part of those records.

Understanding Each Step:

If you are treating for injuries resulting from a car crash, you must take everything you write or speak seriously during each visit. When you are filling out medical paperwork regarding your condition, think before you write.

Likewise, when you speak to your physician about your injuries, be specific and detailed about the pain you are experiencing. You are the author of your own records. Be careful, be honest, and be specific. Because everything you write or speak will be part of a medical record, and an insurance adjuster assigned to your claim will be reading your records with an eye toward denying your claim, not paying it.

While this only scratches the surface on why you need a Rescue Lawyer to handle your personal injury claim – our personal injury attorneys are standing ready to guide you through every step of the process. The right settlements do not come easy. Give us a call. We are ready to rescue you.

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