MEDICAL RECORD OMISSIONS

When we represent clients in personal injury cases there are any number of things that attorneys for insurers can try to use to derail us, to cast doubt on the truthfulness of our clients. Some, although not enormous bombshells in a case, are problematic and come up repeatedly. They are innocent, but made to look otherwise. I’ll discuss one briefly today.

I can’t count how many times a defense attorney has made a huge deal of the fact that a client’s medical record of a doctor visit, close in time to the injury, fails to mention the accident and injury. This happens for a variety of reasons. Sometimes it’s out of our client’s control- the client tells the doctor or other clinician about the problems they are having from their injury event, but the record simply fails to reflect that.

But just as often I ask a client if they know why the record fails to mention the accident and injuries- usually major events in their life- and they tell me they purposefully neglected to discuss it with their doctor because they were there for another issue, and they wanted to “keep it separate.” They are then attacked on the witness stand: how could this neck injury be such a big deal for you if you failed to mention it to your doctor at your general wellness checkup three months later?

Best advice I can give: no matter what your doctor is seeing you for, they are going to do a full “review of systems” at each visit where they survey your overall health- make sure to tell the doctor if you are struggling with and/or seeking treatment for a traumatic injury. They will usually note this, even if this is not what you are seeing them for. It’s the truth, and it helps you avoid problematic medical records later.