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How Do I Document My Care and Injuries?

Each time you see a health care practitioner, a chart notation is made documenting the date of treatment, your complaints and the history that you tell the health care provider, their objective observations, and their assessment of your injuries. In a very real sense your claim will stand or fall based upon what has been written in the medical records and chart notes.

The need to document your injuries and symptoms in the medical record has recently taken even greater importance. Many insurance companies are now using computer programs to evaluate the pain and suffering that can be paid to an injury claimant. Most of these programs rely exclusively on what your treating doctor writes in your medical chart. If an injury or related symptom is not recorded in your medical records, it doesn’t exist as far as the insurance company is concerned. Also, if you do not follow the doctor’s instructions for follow up care, e.g. obtain physical therapy or get an MRI, the insurance company will punish you by reducing the adjuster’s authority to settle your claim. (Read: You will get less money.) This is also true if you are sporadic in getting health care and have “gaps in treatment”.

If a claimant fails to see a doctor and follow up with a medical practitioner, physical therapist or other specialist, there will not be any medical records documenting the condition and its progression, and the insurance company will argue that the lack of documentation proves that the injury was insignificant.

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