Role of Medical Records in Personal Injury Litigation

It’s crucial for doctors to keep clear and accurate records of how they treat their patients. 

Proper medical record-keeping is not only about making sure the treatment is documented correctly but also helps in reviewing and evaluating how the patient was managed.

These records are important for two main reasons:

• They help doctors and hospitals assess patient care, analyze treatment results, and plan future treatments. They also aid in creating healthcare strategies for the future.
• In cases where a patient or their family file for an accident injury claim, these records are the main evidence used in court. They can determine whether a person is responsible or not.

In short, well-maintained medical records protect both the patient and the doctor.

But, How?

Courts consider medical records as strong evidence because they are believed to be genuine and unbiased when documented during a patient’s treatment. 

Records created after a patient is discharged or has passed away don’t hold legal value. Any erasures or deletions in medical records are not allowed and can raise suspicions in court. 

If a correction is needed, the entire line should be crossed out and rewritten with the date and time.

Medical records are often required in court for the following cases:

• Criminal cases – To show the timing, severity, and nature of injuries, helping to confirm the type of weapon used and the cause of death.
• Road traffic accidents – For determining compensation amounts.
• Labor courts – For injury at work claims and Workmen’s Compensation Act cases.
• Insurance claims – To verify the duration of illness or cause of death.
• Medical negligence cases – In criminal courts for charges of negligence or under the Consumer Protection Act for inadequate care by a doctor or hospital.

Doctors are often asked to testify in court and bring medical records. 

When a court requests medical records, it’s a legal obligation to provide them to support justice. An injured person can also submit these documents for personal accident claims. 

What Medical Records Do You Need In a Personal Injury Claim?

Each case will be different based on how serious the injury is and the type of treatment needed. Here are some examples of medical records that could be helpful, but the list is not complete.

It’s a good idea to keep written records of any notes, expenses, or other documents related to your injury. With this information, a personal injury attorney can help decide what’s important for your case.

• Doctor’s diagnosis: This is the most basic and important record. It proves you were injured and can support your case.
• Medical bills: Keep all receipts for medical costs, whether you paid them yourself or through insurance. These will help show how much compensation you need.
• Hospital records: Being admitted to a hospital proves the injury is real. If the records are dated right after the accident, they can also help show that the injury was caused by the accident.
• Doctor’s appointment notes: Detailed notes from your doctor about your condition and treatment can strengthen your case by showing why you need compensation.
• Prescriptions: If you need medications like painkillers or anti-inflammatories, keeping a record of these prescriptions shows the seriousness of your injury and the costs involved.
• Diagnostic tests: Results from tests like X-rays or MRIs help show how bad your injury is.
• Rehabilitation and physical therapy: If you go to physical therapy or rehab, keep records of your sessions. These costs can be reimbursed by the other party.
• Photographs of injuries: Photos of your injuries can be powerful evidence, especially if taken right after the accident.
• Injury journals: You can also keep a personal injury journal, detailing your accident and how you felt afterward. This can be used as evidence in some cases.

Medical records are important for all personal injury cases, but they are especially crucial in medical malpractice claims, which may need extra documentation. 

A personal accident attorney can help you understand which records are required based on the details of your case.