Importance of Medical Records

Medical notes reflect medical management, and not the social, legal, or economic values to be placed on an injury.

Medical notes are the doctor’s memory refreshers and chronologic diary. They concern themselves primarily with what will be treated and with the response to treatment. The attorney should note that the treating physician often becomes committed to and in his own mind justifies everything he puts into writing in his medical notes and in his reports.

More documentation is necessary to establish function loss and impairment which may be compensable by a third party. An effort should be made to establish in the medical records all the complaints, all the limitations, all the functional changes attributable to the injury, and a reason for these in terms of anatomy and physiology.

The usual method of obtaining medial information in through a “release of information” form, but the questions of disability or even functional loss should not be asked until there has been a proper education and commitment to the facts. A “new way” to prepare and request medical records takes time, effort and education.