Personal Injury / Legal

Record Keeping in Personal Injury Cases

Arnold Laub, Esq.

Maintaining evidence of your patients' condition after an injury, during the course of treatment, and afterwards can be a powerful tool for getting the insurance settlement they deserve. This may sound obvious, but how many of these methods do you routinely use in your office?

Videotape the Examination

Every personal injury case that comes into your office should be videotaped. Why? Because you are the only profession that can immediately show results on a camera. Patients walk in after an accident with limitations in their neck and limitations in their back. You film the examination and show that they can hardly move their neck, and show the grimace of pain on their faces when they try to get up from the examining table.

Then you adjust their spine for a few weeks, watch them making progress, and when they can start to move freely, videotape them again on a follow-up examination.

Now, when you come to a situation where you are having a deposition taken three years later, what do you do? You pull out your video, plug it in, and show it at the deposition, and they are going to settle the case.

What a vivid and fantastic way to document what you do.

Patient Diary

Another important way to keep track of a patient's progress is to have them keep a journal or diary, during their post-accident care. When they come in for their adjustments, they might not want to tell you all their complaints. They might not want to seem negative or complaining, so they "accentuate the positive," instead of telling you that the pain in their knees woke them up three nights in a row. Or, perhaps when they see you on Monday, they forget that on Saturday they could hardly move because their back was hurting them. Writing this in their diary, however, helps keep the records accurate.

The diary should reflect how your patient's life has changed as a result of the accident. It should cover how the injuries have affected their activities, and what things they were able to do before, that they now have difficulty doing as a result of the injuries. It should include how the injuries have affected their marital relations, including any personality changes.

The doctor should read, or at least check, the diary once a week to ensure its continuity.

Take Photographs

Have the patients preserve any evidence they have. Any bruises, cuts, or other physical evidence should be photographed in color as soon as possible, so that the full extent of the injuries can be visually preserved.

Any casts, braces, traction devices, or other appliances required in the patients' treatment should be saved. Also, they should be photographed wearing the cast or brace, as further evidence.

The patients should also take photographs of the damage to the car.

Summary

The more precise and vivid your records are, the more likely it is that the insurance company will realize the extent of the damage that your patients have suffered, and pay them for it. Maintaining watertight records is the best way to make the truth unavoidable.

Arnold Laub, Esq.
San Francisco, California

May 1991
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