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How Medical Records Play a Key Role in a Personal Injury Case

Medical Records

Medical records are an integral part of any personal injury case – whether medical malpractice, auto accident, product defect, slip and fall and so on. This makes medical record retrieval an important requirement so that all the relevant medical records are received within the required time. The records are one sure way of knowing what injuries were sustained, the extent of pain and suffering, the treatment provided, ongoing conditions of the patient, and how the injury could affect the patient’s life. Medical record access is governed by regulations established by the Federal Privacy Act of 1974, the HIPAA, the U.S. Department of Health, the state in which the injured person lives, and his/her employer’s policies. The injured person /the person to whom the medical records belong is required to sign a release form to obtain copies of the medical records.

How are medical records used to prove an injured person’s case?

  • They contain information related to the injury and its extent that helps determine whether the case has legal standing.
  • Medical records provide the data required to calculate the damages due, including that for pain and suffering.
  • The information contained also helps estimate the plaintiff’s future damages, if any.
  • It helps understand the cause of the injuries.
  • Also, the records provide proof whether the doctors provided reasonable care.

Medical Documentation to Show Maximum Medical Improvement

Medical records provide information regarding an injured person’s medical improvement or MMI (Maximum Medical Improvement) that is important with regard to claim resolution. It signifies that the person’s condition has stabilized or that the person has recovered completely. The claimant may have to reach MMI before the claim can be resolved. Seriously injured persons may not get back to how they were before even after reaching MMI. In such cases, the treating doctor’s certificate regarding any disability acquired could bring more compensation for non-economic damages such as pain and suffering. To obtain maximum compensation for their clients, personal injury attorneys utilize the service of professional medical record retrieval companies to make sure that the medical record set is complete.

Documentation for Functional Capacity Evaluation

Medical records showing an FCE or Functional Capacity Evaluation is also important in an injury case. Typically, this assessment is recommended by the treating doctor to evaluate the injured person’s capacity to work and may include a cognitive evaluation if there has been a traumatic brain injury involved. The FCE is useful as a record to claim damages based on lost earning capacity.

Medical Records Useful for Settlement Discussions

Accurate and fact-driven medical records are valuable tools even if the case settles out of court. Typically, if the plaintiff can prove his/her claim in court with the evidence in their medical chart, the insurance company may be willing to settle the case out of court. Documentary proof showing the plaintiff’s condition is the best kind of evidence available and is vital for any kind of settlement negotiations.

Written Opinion Vital in Medical Malpractice Lawsuits

Medical records are also vital in a medical malpractice case with regard to the Good Faith Certification requirement. In a medical malpractice lawsuit, the plaintiff or his/her attorney must file a written opinion from a competent healthcare provider practicing in the same/similar specialty as that of the accused practitioner, stating that there is proof of medical negligence. The provider must also include a factual basis for his opinion. In addition to this, a sworn statement from the plaintiff or his/her attorney must also be filed, stating that a reasonable inquiry has been conducted and that the plaintiff’s claim has been filed in good faith belief that it is legitimate.

As a medical record retrieval company assisting personal injury lawyers, we know how important medical records are as one of the strongest forms of legal evidence. They provide the most reliable information regarding the injury, and how it affects/will affect the plaintiff’s life. Therefore, it is important on the part of the plaintiff to ensure that all relevant medical information including medical history is provided, and all test results and other records are submitted. He/she should also follow up on all scheduled appointments and treatments. Medical records are the best proof to win the claim. They help prove economic as well as non-economic damages so that the injured person has a better chance of receiving a higher compensation.

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