Pennsylvania Injury Claims and Medical Records Essentials
Personal injury cases may be won or lost on medical records. They play a crucial role in proving the main elements of a personal injury claim, from evidencing negligent care in a medical malpractice action to supporting damages claims in a car accident claim. A plaintiff cannot receive compensation without proof of an injury and damages in a slip and fall or any accident case, so medical records are the heart of a personal injury case in Pennsylvania.
Linking Injuries to Accidents Through Medical Documentation in PA
Foremost, they help prove a defendant’s negligence harmed the plaintiff. So, for an accident victim who claims that the other vehicle rear-ended them going 45 miles per hour, the medical records describing the location and extent of whiplash injuries from a fierce jolt may corroborate a plaintiff’s story. It may also disprove a defendant driver’s story that they only went 5 miles per hour or did not hit the plaintiff’s vehicle.
Comprehensive Medical Documentation of Injury Severity and Treatment in Personal Injury Claims
Just as critical, medical records show the extent of the injury. In a rear-end collision case, they attest to the severity of the head’s fierce jolting backward and forward that could not have resulted from a mere tap of the rear bumper. The injury location in the neck and shoulders also supports the accident cause, a rear-end collision. Such evidence implicates the defendant as the cause of the accident. Additionally, the justification for the diagnosis, treatment, and prognosis is in the patient’s medical records. Physician notes, lab reports, x-rays, and physical examinations are part of the patient’s medical file. These documents evidence the reason for a physician’s diagnosis and treatment. Doctors follow standard protocols in diagnosing conditions based on symptoms and testing and treat them accordingly. Thus, the medical records reveal an injury’s severity by the diagnosis and course of treatment over days, weeks, or months. Also, the physician’s prognosis is in the patient summaries, dating from the initial consultation to the end of treatment.
Detailed Medical Records That Justify Compensation Demands in Personal Injury Cases
Both plaintiffs and defendants (and their insurers) use medical records to support their cases. The plaintiff seeks to demonstrate the necessity of the treatment, and the defendant attempts to counter with excessive or unnecessary treatment based on the physician’s diagnosis and treatment choices. For example, medical records may show that the physical therapy ordered for the patient’s neck and arm pain is related to a slip and fall accident. The physical therapist’s notes and treatment prove that the treatment length was appropriate since the patient improved only after so many sessions or did not fully improve despite the number of sessions. In other words, a jury or insurer is more likely to accept a plaintiff’s claim for financial losses, such as medical expenses and wage losses, after reviewing the medical records. They support a plaintiff’s economic losses with justification for the weeks or months of employment sick leave, medical expense reimbursements, and future lost earnings.
The session costs and all injury treatments correlate to the severity of the patient’s injury, their medical history, and the type and length of treatment. The records are not merely a subjective narrative of what the patient feels but objective evidence of standard medical diagnosis and treatment found in medical textbooks and endorsed by governing medical authorities.
Critical Components of Medical Records
1. Medical Provider Notes
The plaintiff needs all their medical records to prove a personal injury case. Crucial notes of treating physicians, specialists, and therapists are in them. A treating physician details the patient’s complaints due to an accident injury, typically on the first visit. They take notes from the patient’s subjective experience of their symptoms and then document the results of a physical exam. They may also refer to prior medical history to add to the diagnostic picture. Doctors’ and specialists’ notes, like orthopedists’ notes, include the recommended treatment based on a preliminary diagnosis that may be confirmed by tests the doctor orders. A physician may order pain medications and X-rays or MRIs to better understand the patient’s injuries. Follow-up appointments for assessing treatment and all communications are typically in the patient’s file under the doctor’s notes.
Sometimes, a doctor refers the patient to a specialist who also documents their interactions and actions concerning the patient. A physical therapist likewise details the patient’s specific therapies and exercises for each session and the patient’s feedback or complaints.
Notes from medical professionals who treat the patient enlighten the reader about the nature and extent of the patient’s subjective experience of the injuries, like pain, and the objective diagnostics and treatment administered. Hospital records are also essential to a claim. They show a patient’s picture from intake, whether through the emergency room or walk-in, to discharge. Intake information includes the patient’s reason for the hospital visit, among other information, like their name, address, insurance, and vitals. The examining ER physician’s notes, diagnosis, treatment, and recommendations are also in hospital records.
2. Hospital Records
The hospital records also include any procedures the patient undergoes, such as setting broken bones, splinting sprains, cleaning wounds, stitching lacerations, and administering pain medication. Depending on the nature of the accident and resulting injuries, the patient may receive intravenous medication, undergo surgery, or be released with instructions on home care. Thus, physician, surgeon, and lab reports supply critical information about the severity of the injury and the treatment length. Likewise, the admission and discharge paperwork depict the patient’s initial condition immediately or soon after an accident and the treatment and prognosis. The hospital discharge notes typically instruct the patient on continuing care for wounds, taking medication, and following up with a physician.
3. Diagnostic and Imaging Tests
X-rays, MRIs, CT scans, and other tests administered at the hospital or referred by physicians provide a more precise picture of the plaintiff’s injuries. X-rays show pictures of broken bones or foreign objects lodged in a patient’s body, like glass or debris from a car accident. MRIs show the finer details, a closer look at muscle injuries, tears, and basic soft tissue issues, like ligament and tendon strains or inflammation, possibly nerve damage. They also show bone fractures and brain and spinal injuries. CT scans also show fractures, brain and spinal injuries, blood clots, and internal bleeding. Scan records are the visual story of the severity and extent of a plaintiff’s injuries.
4. Therapy and Rehabilitation Documentation
Other records document the plaintiff’s experience of their injuries and their impact on the patient’s life. Physical therapy reports tell the story of limitations, such as an inability to raise an arm above the shoulder, a painful knee that limits mobility, or the restrictions of a fractured wrist or foot. Physical therapy also gauges the patient’s pain level, determining the exercises and how far to push the patient in rehabilitating injured body parts. Occupational and psychological reports and records also reveal the impact of an injury. An injured employee may see an occupational therapist who assesses the patient’s ability to perform their job or everyday activities and then works with the patient to regain their former activities. Using adaptive tools and equipment, an occupational therapist can help rehabilitate the physical body, coordination, mobility, cognition, and fine motor skills. A psychologist helps a patient deal with the emotional and psychological effects of experiencing and living with debilitating injuries. Depression and anxiety treatment may be included in psychologists’ reports as injured patients often have a difficult time adjusting to a life of limitations, temporarily or permanently. Strained family relations and financial stress due to an incapacitating injury may also be the focus of therapy.
5. Treatment and Medication Records
Therapeutics document the plaintiff’s ongoing treatment and resulting pain and suffering along the timeline of recovery, part objective and part subjective. Medication records document a patient’s pharmaceutical prescriptions, whether for pain, infection, depression, or another malady. Medication records evidence the patient’s condition and severity, depending on the type of medication and dosage. Potential drug side effects are also included in medical reports, which show the exposure or experience of further injury. Allergic reactions to medication can prolong treatment, as indicated in the reports.
Guide for Patients and Their Representatives to Obtaining Your PA Medical Records
Requesting medical records for your Pennsylvania personal injury accident claim is necessary to show all the doctors, specialists, and therapists you saw, the course and length of treatment, and your medical history. In Pennsylvania, you can request and receive your medical records under HIPAA privacy regulations and state law, with few exceptions, regardless of your outstanding medical bills. Your attorney can also obtain your records to pursue a lawsuit. You can complete a form or make a written request, depending on the medical provider. However, you are responsible for paying copy fees regulated by the Pennsylvania Department of Health and HIPPA regulations. A provider has 30 days from your request to view or copy records. They can also deny your request or take up to 60 days to respond when records are off-site. Record holders must also respond to your request for missing documents.
Skilled Injury Firm in PA Utilizes Medical Records to Benefit Your Personal Injury Case
Knowing who to contact and how can be daunting. Fortunately, you can enlist the help of a renowned Pennsylvania personal injury attorney at our firm who knows the laws, rights, and restrictions to help you obtain records. With over 5 decades of experience, we understand how to get, review, organize, and analyze records to map your injuries and treatment chronology. Our injury lawyers regularly use medical records to locate medical providers and insurers who we can contact to discuss and negotiate your claim. Since medical records are the backbone of your personal injury case, we order and use them, not only to mine information for further investigation and evidence, but also to present the story of your accident from beginning to end. Contained in that narrative is your proof of who is liable for your injuries and how much compensation they should be accountable for providing.
Find an experienced personal injury lawyer with expertise and comprehensive knowledge of the techniques to prove your personal injury claim, including obtaining, reviewing, and presenting medical records by getting in touch with us today. We proudly serve clients in Philadelphia, Pittsburgh, Allentown, Erie, Reading, Scranton, Bethlehem, Lancaster, Harrisburg, Altoona, Bensalem, Levittown, and across Pennsylvania. Call us at (215) 337-4915 or contact us via our convenient form for a free consultation to learn more.