Medical Records Are the Case: Documenting Your Injuries From Day One

If I could get every injured person in California to hold on to one idea, it would be this one: the medical record is what proves your case. It counts for more than the photos or how bad the crash looked. When an injury is documented in a medical record, it changes the value of the case dramatically. When it isn't, you're telling the insurance company that these things happened to you, and unless it's written down in a record, they're not going to believe you.

I also know how people end up without that record, and it almost never comes from carelessness. You're shaken up. The ER sends you home. You figure the pain will settle down on its own. Or you've been going to appointments for three weeks, it hasn't done anything for you, and you're tired of sitting in waiting rooms. We understand that. Every one of those reactions is normal, and nobody should feel foolish for having had them.

After a crash, go to an emergency room. At a minimum, go to urgent care. If you're seriously hurt, call an ambulance. But go in understanding what the ER is there for, because it will shape what happens next. The protocol in an emergency room is to look at you and figure out whether anything life-threatening is going on. Do you have an active brain bleed? Are you at risk of paralysis? Is there something that could kill you in the next six, twelve or twenty-four hours? They have a lot of tools for those questions.

Beyond that, they don't have as many. An ER will typically do an X-ray and a CT scan. A CT will show an active brain bleed, but it won't show a mild or even moderate traumatic brain injury the way an MRI might. A real risk to the spinal cord will likely show up on an X-ray. Damage to the structures around the spine, the discs and the nerves, isn't going to lead to paralysis in the short term, so it isn't what the ER is set up to catch.

So ERs are often designed to make sure you're not actively dying and then direct you to your primary care physician. Nobody at the hospital let you down when you were sent home with a clean CT. The ER did its job. The next part is follow-up, and that part is in your hands.

The standard advice at urgent care is go home and rest. There usually isn't a timeline attached. Nobody says to come back in three days if it still hurts. They might say to come back in a few weeks, and doctors will tell you that a lot of times these things calm down: there's some inflammation, and if you give it time, it settles.

The problem is that people don't know what that means. Does it mean waiting six months? So people do what feels responsible. They stretch, they do yoga, they do exercises at home, and some go further and start lifting weights. Some of that can help, but it should happen under the supervision of a trained professional, meaning a physical therapist or a doctor. And the whole time you're working at getting better on your own, nothing about your injury is being written down.

Here's the part I want everyone to hear clearly. Being told to go home and rest doesn't mean you stop seeing doctors. Get to the ER, and then follow up with your primary care doctor if you have one, or at least start some kind of treatment. Don't wait.

A gap in treatment is the most common problem in these claims, and the first thing the other side looks for. It tends to happen in one of two ways.

In the first, someone gets into a car accident and doesn't get treatment for six months because they think rest will take care of it. Whether they're getting better or not, nothing is documented, so the record makes it look like they did nothing. When they finally want to see a doctor, the insurance company's answer is that they never went in the first place, so it won't pay for any medical care. Plenty of people never think about a claim until three, four or six months go by and their back still hasn't gotten better. By then there may be one ER visit, a "go and rest," and no follow-up, which leaves no way to show they were hurting the whole time.

In the second, someone treats for two or three months, gets worn out from going to the doctor so often, and stops for a month or two. Then the pain comes back badly and they want to know what can be done. The insurance company's position becomes that treatment ended when they stopped, and it isn't paying for anything going forward. This happens to people with lawyers and people without them. A personal injury attorney like me can often deal with it, but it isn't easy. The explanation has to be clear, and the person handling it has to be confident enough not to accept the insurance company's word as final.

I get why people stop. Some of these injuries stay with people for months, often years, sometimes decades, and three weeks of appointments that don't seem to help is discouraging. Treatment matters, but what matters just as much is that the chart keeps saying the truth: you've kept going, and the pain hasn't gone away. In front of a jury, a gap gets described as proof that you weren't hurt. Nobody on the other side will call it a responsible person trying to get better before running up medical bills. Your records are what answer that.

Doctors write down what you tell them, and what you tell them is shaped by whatever hurts most. Say you have a fractured collarbone where your seatbelt was. That may be your primary complaint, with the pain at a nine out of ten. Maybe you also have a headache, you feel dizzy and out of it, and you're chalking that up to the collarbone. Say it anyway. Tell them you're dizzy, you're forgetful, you have a headache, and the shoulder is what's bothering you most. Later, once the collarbone heals normally and a brain injury hasn't, the value of that case is a lot of times going to hinge on whether the head trauma was reported at the hospital.

The same goes for every visit after that one. Mentioning a symptom once doesn't keep it on the record. If sleep, memory, word-finding or mood is still a problem, it belongs in each visit's notes. A single record where you mention one or two symptoms and leave out the rest is the record the other side will hold up and say you were fine.

Be careful with how you describe getting better, too. Someone in chiropractic care might say they're 70% better, then a month later say they feel 95% better. That may be true on that day. It may be true only while they're getting treatment four times a week, and as soon as the treatment stops, the spine starts hurting more every day. A lifetime of chiropractic care is not a prescription. If someone needs that much care, they need to see a specialist, and the specialist needs imaging to figure out what's going on.

Then there's the line almost everyone says at some point: "my back's a little sore, but I'm fine." It's a polite, natural thing to say. The trouble is that it gets recorded, in a chart or on a call with an adjuster, and later the whole claim gets measured against it. The same person can turn out to have a pretty damaged spine, with a lot more pain once the adrenaline wears off. Describe what you feel without rounding it down.

Even the question of how the crash happened ends up in the chart. People are shaken up and tell the doctor they don't remember how it happened, and that can later be used to suggest they don't know whether they ran the light. A month or two later, once they've calmed down, they may remember clearly that they had a green. I don't want anyone on guard with their own doctor. I want you to know that what you say in that room travels.

Even a strong record gets challenged. The insurance company is going to hire a different doctor who disagrees with your treating doctors' reports, and I can tell you with complete certainty that the disagreement will come, because it comes every time to at least some degree. It may not be that you're completely lying. It'll be that you're 90% or 50% or 25% overstating it.

Getting better is still the point. We hope our clients get better. We try to give them every tool to get better, and we refer them to the best specialists, the best surgeons and the best brain doctors we can, because getting people the treatment they need is our job. But if someone isn't getting better, they should say they're not getting better. People sometimes hold back because they think they'll hurt the doctor's feelings. That isn't the case. A record that matches your life is what tells everyone, including a jury, where the claim should go.