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Personal injury medical records

Personal injury medical records

Proving your case

The roles of the attorney and legal nurse consultant in personal/bodily injury litigation center around identifying, assessing, presenting or refuting the injuries/damages related to the accident. Careful analysis of the records generated after an accident can reveal crucial information about the case. The questions listed below are designed to stimulate thinking about the plaintiff’s medical condition before and after trauma. Our company provides this type of analysis to assist plaintiff and defense attorneys in making appropriate legal decisions based on the medical issues in a case. We don’t want our clients being surprised in the courtroom by relevant medical information.

Analysis of Physician Office Records

1. How did the plaintiff describe his or her health prior to the accident? Was this individual normally healthy or were there many chronic illnesses? Look particularly for evidence of arthritis, lupus, diabetes, hypothyroidism or hyperthyroidism, and exposure to toxic substances.

2. What medications was the plaintiff taking before the accident? This will provide clues as to chronic illnesses or pre-existing pain. If necessary, obtain pharmacy records.

3. What do previous medical records say about the plaintiff’s prior accidents or workers compensation claims?

4. Did the plaintiff have any diagnostic testing prior to the accident documenting pre-existing injuries? When the plaintiff is claiming back injuries, look particularly for diagnostic testing for back injuries: MRI, CT Scan, electromyography, etc. If disc pathology was noted, was it described as a herniated disc or merely a bulge?

5. Did the plaintiff have any psychiatric illnesses before or after the accident? Look for evidence of frequent trips to the physician for minor ailments (the patient may have hypochondriasis or somatization disorder), depression, or stress-related illnesses (irritable bowel syndrome, peptic ulcers, and so on).

6. Did the plaintiff have any respiratory conditions that resulted in frequent coughing, such as asthma, allergies, or emphysema? This can put asthma, allergies, or emphysema? This can put pressure on vertebral discs.

7. Was the plaintiff employed before the accident? What type of work was performed?

8. Did the plaintiff’s work require a great deal of physical effort (which may have caused some chronic injuries?) Was there an opportunity for repetitive trauma in the activities associated with the job? Did the job involve handling vibrating equipment, such as jackhammers? Was the person driving long distances, which can cause neck injuries from the repetitive turning of the head, or back injuries from rough roads?

9. Did the plaintiff have hobbies that would have caused injuries? Look for participation in sports, weight lifting, martial arts, diving, driving dirt bikes or other vehicles over rough roads, jogging, golfing and other activities that can cause injury.

10. Did the plaintiff smoke? This can accelerate degeneration of a disk.

11. Was the plaintiff able to return to work after recovery and if so, when? Review of personnel or employee health records may be necessary.

12. Are there inconsistencies in the medical records about the symptoms the plaintiff displayed after the accident?

13. If the plaintiff developed a one-sided herniated disk, does the pain run down the plaintiff’s leg (radiculopathy) and does the side correspond to the side of the herniation?

14. When back injuries are being claimed, did the plaintiff follow the doctor’s advice to lose weight to reduce stress on the back? Look for the diagnosis “mechanical low back pain”, which refers to stress on the back from obesity.

15. Do the medical records comment that the plaintiff was complaining of a stocking-glove distribution of numbness or tingling or non-anatomic pattern? These complaints are inconsistent with those expected if a herniated disc is involved in pressing on a specific nerve root.

16. What comments about how the accident occurred were recorded in the medical records? Are there discrepancies about how the accident happened?

17. Did the plaintiff lose consciousness after the accident? Is the plaintiff claiming post-traumatic stress disorder? These two are incompatible. The plaintiff must have been subjected to a sudden traumatic event and have a recollection of the event in order to develop PTSD.

18. If the plaintiff is claiming cognitive losses after a head injury, what was the plaintiff’s pre-accident level of functioning? School, military and employment records may reveal the baseline.

19. Did the plaintiff have any chiropractic treatment before the accident? This may reveal pre-existing back problems. Did the person have any chiropractic treatment after the accident? Improper, forceful chiropractic manipulations can cause disc herniations, brachial plexus injury, and arterial damage.

20. Is there evidence that the plaintiff withheld information from the treating doctor?

21.Did the plaintiff refuse to have certain diagnostic tests performed? What was the explanation for the refusal? Did the insurance company cut off benefits?

22. Was the plaintiff compliant with medical treatment? Look for entries such as DNS (Did Not Show) or DNKA (Did Not Keep Appointment).

23. Did the plaintiff follow the advice to avoid weight bearing on a leg before it was allowed?

24. If the plaintiff had back surgery, did he recover in an expected way? Is there any evidence that the plaintiff did not obtain relief from symptoms? If the plaintiff had a failed fusion (pseudoarthrosis), is there any indication that the plaintiff smoked or gained weight, which increases the risk of a failed fusion?

25. Was the plaintiff observed to be wearing the prescribed braces, collars and using the assistive devices (walkers, canes, and wheelchairs)?

26. If one limb was described as weaker than the other, was there evidence of atrophy (muscle wasting) of the affected limb?

27. Did the plaintiff take the prescribed medications for the recommended period of time? If not, ascertain why the plaintiff stopped or varied the prescribed drug regimen.

28. Did the trauma bring to light a previously undiagnosed medical problem with no causal relationship to the injury?

29. What medications was the plaintiff on after the accident? Do any of the medications have side effects that include headaches, joint pains, depression, memory loss, weakness, dizziness, and other symptoms the plaintiff may be claiming resulted from the injury?

30. Was the plaintiff treating with more than one physician at a time? Were narcotic prescriptions being obtained from more than one physician at a time? Did the plaintiff contact the physician at any point claiming to have lost a prescription for a narcotic?

31. Did the plaintiff use more than one pharmacy to fill prescriptions? Do the records of these pharmacies reflect overlapping prescriptions written by more than one doctor?

32. Were the claimed injuries objective or subjective?

33. Are any or all of the injuries documented soft tissue injuries?

34. How long did the symptoms persist after the accident? A duration of at least 6-12 months is needed to establish permanency.

35. Was there any evidence of physical abuse of the plaintiff by a family member or someone else, which may have contributed to the injuries?

36. Were the injuries consistent with the mechanism of the injury? Look for evidence of star-shaped patterns on the windshield with head injuries, or hyperflexion/ hyperextension type descriptions. Look for dashboard damage if a knee injury is claimed. Look for seat belt-type injuries (abrasions on the neck, chest, and abdomen).

37. Did any post-trauma x-rays comment on pre-existing degenerative changes? (osteophytes, arthritic changes, degenerative joint changes, scoliosis, spondylolysis, joint facet hypertrophy, spinal stenosis, foraminal stenosis, or other chronic changes.)

38. Did an abnormality show up on the second MRI after a back injury, but not the first? Was there a history or possibility of another trauma after the first MRI?

39. Was the diagnosis of the injury supported by the doctor’s examination?

40. Were the services actually performed on the date or does the bill include charges for dates the plaintiff was not seen, or for which there are no office notes?

41. Did the typed reports or correspondence to other doctors match the information in the handwritten notes?

42. Are the facts in the history correct? Do they match the rescue squad and ER records? Did the plaintiff deny the loss of consciousness at the time of the accident, but later claim that he did lose consciousness? Did the plaintiff say she was unbelted at the time of the accident, but later claim to have been restrained?

43. How often did the doctor see the plaintiff after the injury? At what point did the doctor state the plaintiff had reached maximum medical improvement (MMI)? Is there any correlation between the plaintiff’s maximum medical improvement and the date the insurance company stated it would stop paying for services? Is there any indication of medical malpractice in the physician office?

Analysis of Physical Therapy Factors Affecting Personal Injury Cases

1. When was the therapy supposed to begin? Did the plaintiff begin therapy as soon as it was recommended?

2. How often was the plaintiff seen? Over how many weeks was the plaintiff seen? (Over six weeks is questionable.)

3. Did the frequency of visits remain the same?

4. Of the scheduled number of visits, how many did the plaintiff attend?

5. What did the therapists document about the plaintiff’s condition during these visits? Were there any discrepancies in the behavior of the plaintiff during therapy?

6. Did the therapist document any other injuries that occurred during this time frame?

7. Did the plaintiff’s complaints match the complaints recorded in the doctor’s office?

8. Did range of motion measurements improve with treatment?

Analysis of Attorney Factors Affecting Personal Injury Cases

1. Do the emergency room or physician records state the plaintiff attorney referred the plaintiff?

2. Did the plaintiff contact the plaintiff attorney before contacting a doctor after the accident?

3. Do the doctor’s records state the plaintiff attorney referred the plaintiff to the doctor?

4. Do the doctor’s medical records contain any references to phone calls with the plaintiff attorney?

5. Do the doctor’s records contain any implications that the plaintiff attorney was directing the plaintiff’s care?

6. Do the doctor’s records contain any implications that the plaintiff attorney requested a revision of a report to favor the plaintiff?


Contact Us and we can assist with locating nursing and physician experts, retrieval of articles supporting the standard of care, preparation of timelines and chronologies, and other demonstrative evidence.

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