Why Your Medical Records Matter in Personal Injury Cases

The subject has come up too many times in the past couple weeks where clients are disputing what is documented in their medical records that were written by their own treating physicians. I will admit, prior to becoming an attorney in South Carolina, I would trust what the doctor told me in the private setting of the examination room. As Lee Corso says, "Not so fast my friend."

It does not matter if you are being assisted by Medshore EMS at the scene of a motor vehicle collision or talking to your long time AnMed Family Medicine physician, those medical providers are documenting everything you tell them. As a matter of fact, the Federal Government has mandated all records be made digitally so you can even read the physician's handwriting. Well that wasn't their main reason for doing it but it sure has helped in reading Dr. Wadee's records. 

You have the right to request your medical records and you should do that on a quarterly to annual basis depending upon your frequency in medical treatment. (No, the discharge or checkout paper you get does not count as a medical record that is important.) It will help you see what information is documented from your visit with medical providers and also help ensure that your medical concerns and complaints are actually being addressed. Let me provide a news flash when that may become relevant...IN A PERSONAL INJURYCASE! 

If you are involved in some kind of traumatic incident (workers' compensation claim, car wreck, dog bite, slip & fall, product liability claim, nursing home negligence, or medical malpractice case) and claim the injuries you sustained from that incident are all because of that traumatic incident, you have to prove it to be reimbursed by the evil insurance companies. Your back may be hurting but if just the week before you were complaining of back pains, the question becomes how much more, if any, is your back hurting from the traumatic incident. Don't come in telling me your life is changed forever for the worst because of this traumatic incident but have no medical documentation to prove that claim. 

As an attorney, I can not tell the evil insurance company that your doctor told you it was all because of the traumatic incident. Shockingly, the evil empire would not believe me or you. However, the evil tryanny sometimes believes what is in the medical records. Not all the time but let's not get caught up in the fact that the evil empire will have a 22 year old college, educated adjuster make medical diagnosis and decisions. We will save that subject for another article. 

Today, your take away is this:

  • You are legally entitled to a copy of your medical records, regardless if you owe a balance to the medical provider. Now there may be a copying charge or retrieval fee but you are still entitled to those printed and detailed records, along with your itemized bills. Click here to print off this page, if the gate keeper at your medical facility doesn't believe you.
  • Do you really know what your doctor has documented?   What do you think your doctor will depend on as the truth a year from their visit with you if asked by a lawyer? That exact conversation or their medical records?
  • What is documented in your medical records will help your recovery from a traumatic incident or help the evil empire against your recovery. So, if you are experience back pain, emotional trauma, sleepless nights, relationship troubles, and so forth, I better read it in the medical records or it is not happening!

 

 

***When I Googled "evil insurance companies" there was a link with a discussion of whether insurance companies were evil or stupid.  Although it was about health care, the liability insurance carriers are designed the same way, maximize return to their shareholders while minimizing the payout of claims (YOUR CLAIM). I thought this was a very interesting response:

Doug DingusEverybody pays, everybody covered
622 Views
Insurance companies have a basic conflict with us in that their goal is to maximize for the shareholders, and that happens best when they deliver the least health care access for the most dollars.

So, the answer is by design, but said design is an artifact of our health care policy, meaning they are neither stupid or evil.

We can remedy this with regulation, or public primary care insurance, or competition, depending on how said competition is structured

Do You Know What Your Doctor Said?: Medical Records & Treatment

A recent article in the Wall Street Journal entitled, "Access to Doctor's Notes Aids Patients' Treatment", highlights an interesting topic of patients actually reading, or requesting,  their medical records from visits with their primary care physician

The study was entitled "OpenNotes" and published in the Annals of Internal Medicine. Ultimately the study concluded that an overwhelming 77% to 87% of patients felt more in control of their medical care and were more compliant with their prescription medication.  Initially, there were concerns from  physicians that their notes may offend or scare off patients but 105 primary care physicians participated in the study. Interestingly, the article points out that only about 34% of doctors nationwide have adopted electronic medical records.

From the perspective of this plaintiff's attorney, when you think about the other audiences reviewing your records:

  1. referring physicians to further your care; (Good)
  2. insurance companies and adjusters to deny your medical benefits to save them money; (Bad) and
  3. both plaintiff and defense attorneys for disputes in personal injuries, workers' compensation claims, and/or social security disability claims. (Good & Bad)

The only logical step is to ensure you as a patient are just as knowledgeable of your own records as the jack legged insurance adjuster combing through your file to find anything to deny you benefits you deserve, while falsely acting as if they have medical degrees.

In the end you know, it is your body and your life. Yes, you are legally entitled to those records, too.

 

 

Injured at Work in South Carolina? What you need to know. (Part 2)

This is the second of a series of blogs written to tell workers in South Carolina what they need to do if they suffer a work-related injury.  

2.    Tell the treating doctor that you got hurt at work!

In my previous blog, I stressed the importance of reporting your work injury immediately to your employer.  Today, I stress the importance of telling your doctor that you got hurt at work and how you got hurt at work.

In many denied workers’ compensation claims, there is, for lack of a better word, a swearing match going on between the injured worker and the employer.  The worker claims to have been injured on the job.  The employer denies that the worker got injured on the job or claims that the injured worker did not properly report his injury to the employer.  The workers’ compensation commissioner is charged with the responsibility of finding the truth and, therefore, must decide which one to believe.  

In my experience, the commissioner often relies on the medical records to break the tie.  He discounts the injured worker’s testimony as well as the employer’s denial because they are both taking self-serving positions.  Then, he especially looks at the initial medical record of treatment of the injured worker to find the truth because he assumes that the initial treating doctor does not “have a dog in the fight.”  If the initial medical record documents that the employee was being treated due to an injury that the employee contends occurred at work, and especially if the record describes how the injury occurred, the commissioner will view that record as giving credibility to the injured worker’s claim.  On the other hand, if the injured worker does not mention anything about the work injury to the initial treating doctor, the commissioner will likely view that record as giving credibility to the employer’s defense that the employee did not get hurt at work.

Therefore, if you were injured at work, it is imperative that you document that you are at the doctor’s office seeking treatment for an injury that occurred at work on all of the forms that the doctor’s staff may ask you to complete prior to your examination and then you must describe the injury to the doctor when he examines you so that he will include it in your medical record.  

As a general rule, the more details that you can give to the doctor, the more believable your claim will be to a commissioner.  For example:

  • know the exact date of your injury before you go into the doctor’s office.  Do not guess at your date of injury because it will come back to haunt you if your claim is contested and the date of injury that you give the doctor is wrong.  I have seen situations where the injured worker haphazardly reports to the doctor that he got hurt at work on Wednesday about two weeks ago and then prior to the workers’ compensation hearing we learn from  reviewing his time cards that the worker did not even work on that Wednesday.  At that point after closer examination, we realized that the injury actually occurred on Wednesday, but it was three weeks ago rather than two weeks ago as reported to the doctor.  That is an error that can be explained and corrected, but it could have been avoided all together if the worker had been prepared when he initially went to the doctor.
  • be specific in your description of the injury to the doctor.  Which is more believable?

    • “I hurt my back at work last Wednesday just doing my job;” or
    • “Last Wednesday afternoon at work, I injured my back lifting a 75 pound box  off of the floor.  I was going to put the box on my work table.  As I twisted while lifting up the box, I felt a sharp pain in my lower back and pain even went down my left leg.  I had to put the box back down on the floor and was never able to lift it up to the table.”

In conclusion, it is imperative that you give your doctor specific details about your work-related injury during your first medical appointment after the injury.  If you do so, the employer and insurance carrier will likely admit that you got hurt at work and will provide you with workers’ compensation coverage without unnecessary delay.

My next blog will be about the fact that you can suffer a work injury without being required to suffer trauma.


 

(Ernie Trammell is the author of this blog post and subsequent posts on Workers' Compensation in South Carolina. Mr. Trammell has been a Workers' Compensation attorney in South Carolina for 29 years, primarily in the Upstate encompassing the counties of AndersonAbbevilleGreenvilleGreenwoodLaurensOconeePickens, and Spartanburg.) 

South Carolina Medical Professionals Cheat Sheet to Legal Depositions

I am a lawyer not a doctor. Doctors are medical professionals trying to help people get better by diagnosing, treating, and preventing. When we step outside our profession and into another professional arena we know very little about, it can be confusing. No matter how much reality television we watch, it may not carry over to the realities we live in.

In the short time I have been an attorney, it never ceases to make me laugh when I go to a doctor's deposition. We, as lawyers, have to ask certain questions in certain ways to meet legal thresholds and adhere to the prevailing rules of evidence, which makes those questions sound verbose, obnoxious, and confusing.

  1. "Doctor  ______, is it your opinion to a reasonable degree of medical certainty that it is more probable than not, that my client's disc herniation were caused/aggravated/ and/or made worse from the motor vehicle collision/slip and fall/dog bite?"
  2. "Doctor ______, based on your education, observations, and medical treatment of my client, was it medically necessary to send them for physical therapy/diagnostic testing/pain management as a result of the motor vehicle collision/slip and fall/dog bite?"
  3. "Doctor ______, do you have an opinion to a reasonable degree of medical certainty as to the permanent impairments my client would be assigned under the AMA guidelines?"

It's important for medical professionals to understand that Plaintiffs have the burden of proving their case by the preponderance of the evidence. The most common example is the tipping of the scales of justice ever so slightly to provide an imbalance that would warrant the "preponderance" part, "more likely than not". (David Swanner of South Carolina Trial Law Blog gives several good examples).

Therefore, medical professionals don't have to know 100% one way or the other. They just have to give an opinion (based on a reasonable degree of medical certainty) whether an injury or aggravation of a pre-existing injury is "more likely than not"/ "more than a 50% chance"/ "ever so slightly tips the scales" was caused or directly affected by the trauma.

Plus, know what you charge for your office visits. You are a professional and are running a business. In the 100 or more medical depositions that I have taken, not one medical professional has been able to tell me what they charge per office visit. That could be one explanation in the health insurance and medical professional struggle now. How can you talk about lost profits and exorbitant prices when you have no clue about money, fees, or service costs directly related to services rendered?

This is the typical response cut and pasted directly from an recent examination of my client's treating physician's deposition:

I can't make an assessment about causation.  When I see a patient or take care of patients, I'm not really thinking about, you know, is this going to go to a legal situation. I'm mostly concerned about the patients and their well-being so I just go what they tell me, by the history.  So the answer to your question is:  I don't know.  I can't say with 100 percent certainty that the motor vehicle accident caused the herniated disk.

I asked the questions previously discussed. Do you have an opinion? Not can you tell me for certain. Plus, if you were truly concerned for the patient, you would also be concerned about the financial stress and misery of undergoing medical treatment and being personally responsible for the medical services you have rendered to them unless you agree that someone else affected their pre-existing injury or caused new injuries.