How to Collect and Save Medical Records in a Personal Injury Claim

In a personal injury claim, medical records are vital to establishing the cost of care (and any proposed statement or settlement). If you're navigating the personal injury claim process after an accident, be sure to understand the types of records needed, and what information within those records is most relevant to your claim.

Types of Medical Records to Collect

Here are some of the types of medical records to preserve after an accident: 

• Initial medical records: These are records obtained from any initial treatment you receive after an accident. Common initial records include:

• Emergency room records: Document the procedures, tests, operations, and diagnoses that an ER administers.
• Doctor's office visit notes: Any after-visit summaries, tests, conversations, and treatment recommendations offered by your primary care provider.
• Prescriptions: Any medications prescribed to you, either from an emergency room provider or your primary care physician.
• Test results: Any results collected from medical tests, including blood work, X-ray scans, MRI scans, etc.

• Follow-up and ongoing medical records: These are records from any follow-up visits taken after your initial post-accident treatment. Common follow-up records include:
  

• Ongoing doctor's office visit notes: Further after-visit summaries, tests, conversations, and treatment recommendations offered by your primary care provider.
• Specialist consultations: Any after-visit summaries, tests, conversations, and treatment recommendations offered by a medical specialist on referral.
• Physical therapy records: Any visits to a physical therapist, including recommended treatment plans and recovery progression tracking.
• Hospitalization records: Any new outpatient or inpatient hospital visits after initial treatment.

• Surgical records: Any new surgical procedures completed after initial treatment, including recovery timeframes.

• Medications and therapies: Any additional prescriptions or therapy recommendations offered after the initial diagnosis.

Relevant Information in Medical Records

The information contained within your medical records will underline your claim. Your attorney will review records to determine the extent of your injury, which impacts the amount of money you’ll seek in a claim.

Here are some common figures that impact a personal injury claim:

• Diagnosis: Specific injuries or illnesses you’ve sustained, as determined by a medical professional. You’ll see this diagnosis in your after-visit summary, and it will be shared with all other providers who access your electronic health record (EHR).
• Treatment: Any treatments you’ve received because of your injury, including medical, mental, and physical procedures. This will include all medications, surgeries, and therapies.
• Prognosis: The expected outcome of your injuries or illnesses, as determined by a medical professional.
• Lost wages or earning capacity: Documentation of missed work or reduced earning potential.
• Pain and suffering: Any evidence of physical and emotional pain and suffering.
• Future medical needs: Anticipated future medical expenses.

Tips for Collecting and Saving Medical Records

Most medical providers will document your information in an electronic health record, or EHR. However, if you visit multiple providers in different health systems, your medical information might not easily transfer from one system to another. 

Here are some tips to preserve your medical information during the case:

• Be proactive: Request copies of medical records as soon as possible.
• Keep organized: Maintain a local file or digital folder for all medical records.
• Obtain original copies: Whenever possible, obtain original paper copies of medical records.
• Verify accuracy: Ensure that all records are complete and accurate.

A personal injury attorney can provide guidance on which records are most relevant to the case. If you have any questions or need help pursuing a personal injury claim, contact our team with the form below.