The Extreme Importance of Good Medical Documentation
When it comes time to get a negligence case settled, nothing is more important than good medical records. And writing good medical records falls solely within the province of the client's treating doctors. I have been disappointed with the failure of some of the treating physicians in my community to properly document their files. I have even gone so far as offering to meet and explain (at my expense) what should be in the records, and have been blown off. The doctor in question had his lawyer call and tell me he did not want to talk to me either in person or by phone. So, my client's case took a hit. The bottom line was much smaller than if the doctor had done a half way decent job.
What do I look for in a decent final report:
1. That the patient is discharged with or without a "permanent impairment." A permanent impairment is medical talk meaning the patient now has a permanent handicap of some sort due to the accident.
2. That the patient has or has not got any permanent restrictions or limitations due to the accident. For example, I have a client who had a rotator cuff injury and two surgeries to repair it. He can no longer lift more than 5 lbs., or use his arm repetitively, or lift it above his head.
3. The projected cost of future medical care, the type of care, and frequency. Such as an MRI once a year, future epidural injections, pain meds, and blood tests to check the patient's liver to see if they are being damaged by pain pills or other medications that are prescribed.
4. A medical decision correlating the treatment to the accident, or deciding it is not related. I recently asked for such a decision from an orthopedic surgeon, and he sent me a letter saying "maybe" it is related. Big Deal. Maybe it is not. The letter will be useless in convincing the adjuster his insured caused the injury.
5. Last but not least, a fair comment on the level of "discomfort" (PAIN) which the client has reported to the doctor. I need the doctor to honestly report what the patient is really saying, not just that he thinks surgery or treatment was a "success."
I practice in a small community and there is really not a lot of choices locally, but a short drive to another nearby city makes it possible to get a better doctor. If they can make the trip it enables them to see doctors who are not only competent in the medical side, but also, and just as important, competent in writing good final reports. An experienced Personal Injury lawyer learns who they are and can direct clients to the good docs as part of his advice. I think some doctors are introverted and afraid of going to court and just don't care about the legal side of the medical treatment.
That's too bad, because medical ethics mandate a doctor to stand up as a medical witness to help lay people (like jurors or adjusters) understand what the patient has gone through and will be going through. It is unethical in my opinion to dodge that by poor report writing.
