Using Your Medical Records to Support Your Personal Injury Claim

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Medical records are one of the most important pieces of evidence in personal injury claims, providing objective documentation of your injuries and treatment. While disclosing medical records may feel intrusive, it’s essential for building a strong case and is handled confidentially by legal professionals.

When pursuing a personal injury claim, your medical records play a vital role in establishing the extent of your injuries and their impact on your life. Here explain why medical records are so important, how they’re used in your claim, and address common concerns about privacy and disclosure.

Why Medical Records Matter in Personal Injury Claims

Medical records are the cornerstone of any personal injury claim, providing objective and detailed evidence of your injuries and their impact. They serve several purposes that can significantly influence the outcome of your case:

  1. Documenting injuries: Medical records provide a professional, unbiased account of your injuries. This documentation offers a clear timeline of your medical condition from the moment of the accident onwards.
  2. Establishing causation: One of the key elements in a personal injury claim is proving that your injuries were caused by the accident in question. Medical records can help link your injuries directly to the incident, strengthening your case.
  3. Detailing treatment: Your records outline all the medical care you’ve received, from emergency treatment to ongoing therapy. This information is vital in demonstrating the extent of your injuries and the efforts made towards your recovery.
  4. Demonstrating impact: Beyond just listing your injuries, medical records can show how these injuries have affected your daily life and work. This could include notes on physical limitations, pain levels, and inability to perform certain tasks.
  5. Calculating damages: The detailed information in your medical records helps in determining appropriate compensation. This includes not just current medical expenses, but also projections for future care needs.

By providing this comprehensive view of your injuries and their consequences, medical records form the foundation upon which your entire claim is built.

Types of Medical Records Used in Claims

Personal injury claims may draw upon a wide range of medical documentation to build a complete picture of your injuries and their impact. The types of records used can vary depending on the nature and severity of your injuries, but commonly include:

  • GP records: These provide a history of your health before and after the accident, which can be key to establishing the impact of your injuries.
  • Hospital admission and discharge notes: These documents offer detailed information about your immediate post-accident condition and the initial treatment you received.
  • Surgical reports: If you required surgery as a result of your injuries, these reports provide in-depth information about the procedures performed.
  • Diagnostic test results (X-rays, MRIs, CT scans): These offer objective evidence of your injuries, which can be particularly compelling in negotiations or court proceedings.
  • Therapy and rehabilitation records: These demonstrate the ongoing impact of your injuries and the efforts you’re making towards recovery.
  • Mental health treatment records: If you’ve experienced psychological trauma as a result of the accident, these records can support claims for emotional distress.
  • Medication histories: These can show the extent of pain management required and any side effects you’ve experienced from your treatment.

Each of these record types contributes unique and valuable information to your claim, helping to create a comprehensive picture of your injuries and their impact on your life. Your solicitor will review all available records to determine which are most relevant and persuasive for your specific case.

The Process of Obtaining and Using Medical Records

The process of obtaining and utilising medical records in a personal injury claim involves several steps to build a strong case:

  1. Consent: The first step is obtaining your consent. You’ll need to sign a medical release form allowing your solicitor to access your records. This form typically specifies which healthcare providers can release your information and for what time period. It’s important to read this form carefully and ask any questions you might have before signing.
  2. Retrieval: Once consent is obtained, your solicitor will request relevant records from your healthcare providers. This can include your GP, hospitals, specialists, and any other medical professionals who have treated you in relation to your injury. The retrieval process can take several weeks, as healthcare providers often have a backlog of record requests to process.
  3. Review: After receiving your records, a medical expert will thoroughly examine them. This expert is usually a specialist in the field relevant to your injuries. They’ll review your medical history, the details of your injury, treatments you’ve received, and your prognosis. This review is crucial in understanding the full extent and impact of your injuries.
  4. Report: Based on their review of your records and potentially a physical examination, the medical expert will produce a detailed report. This report will typically include:
    • A summary of your injuries
    • An opinion on whether your injuries are consistent with the accident described
    • Details of your treatment and recovery
    • A prognosis for your future health and any ongoing care needs
    • An assessment of how your injuries have affected and may continue to affect your life
  5. Negotiation: Your solicitor will use this medical report as a key piece of evidence in negotiating your compensation. They’ll use the information to argue for a settlement that fully accounts for your injuries, treatment costs, and the impact on your life.

Throughout this process, your solicitor will keep you informed and may ask for additional information or clarification as needed. It’s a thorough and sometimes lengthy process, but it’s essential for building a strong, evidence-based claim for your compensation.

Addressing Privacy Concerns

It’s natural to feel apprehensive about sharing your medical history. The idea of strangers poring over your personal health information can be uncomfortable. However, it’s important to understand how this information is handled and protected:

  • Only relevant information is used in your claim: Your solicitor will only request and use medical records that are directly relevant to your injury claim. They won’t be looking at unrelated medical history unless it has a bearing on your current injuries.
  • Your records are handled confidentially by legal and medical professionals: All parties involved in reviewing your medical records are bound by strict confidentiality rules. This includes your solicitor, medical experts, and even the opposing party’s legal team.
  • Disclosure is limited to parties directly involved in your claim: Your medical information won’t be shared with anyone who isn’t directly involved in assessing or negotiating your claim.
  • You have the right to review any medical reports before they’re shared with the other party: This gives you the opportunity to check for accuracy and raise any concerns before the information is used in your claim.

Remember, the purpose of disclosing your medical records is to support your claim and ensure you receive fair compensation. The professionals handling your case understand the sensitive nature of this information and have systems in place to protect your privacy.

The Importance of Full Disclosure

While it might be tempting to withhold certain medical information, especially if you think it might negatively impact your claim, it’s important to be fully transparent:

  • Failing to disclose relevant medical history can severely damage your claim: If it’s discovered that you’ve withheld important medical information, it could undermine your entire case and potentially lead to accusations of fraud.
  • Pre-existing conditions don’t necessarily hurt your case and may even strengthen it if the accident exacerbated them: In fact, if the accident has worsened a pre-existing condition, this could potentially increase your compensation.
  • Your solicitor needs complete information to build the strongest possible case for you: Without full disclosure, your solicitor can’t anticipate potential challenges to your claim or develop strategies to address them.

Being honest and upfront about your medical history allows your solicitor to present your case in the most accurate and favourable light. It also prevents the risk of your claim being undermined by information that comes to light later in the process.

What If You Refuse to Disclose Medical Records?

Refusing to disclose your medical records can have serious consequences for your personal injury claim:

  • It may be seen as a breach of your agreement with your solicitor: When you engage a solicitor, you typically agree to provide all necessary information for your claim. Refusing to disclose medical records could be considered a violation of this agreement.
  • You could face financial penalties for costs incurred by your solicitor: If your solicitor has already begun work on your case and you then refuse to provide medical records, you might be liable for the costs they’ve incurred up to that point.
  • Your claim may be significantly weakened or even dismissed: Without medical evidence, it’s extremely difficult to prove the extent of your injuries and their impact. This could result in your claim being undervalued or, in some cases, thrown out entirely.

It’s important to understand that while you have the right to refuse disclosure, doing so can effectively end your claim. If you have concerns about disclosing your medical records, it’s best to discuss these with your solicitor. They can often address your worries and explain why the information is necessary for your case.

Challenging Inaccuracies in Medical Records

Sometimes, you may find that your medical records contain errors or inaccuracies. This is not uncommon, but it’s crucial to address these issues promptly:

  1. Discuss the discrepancies with your solicitor immediately: If you notice any errors in your medical records, inform your solicitor as soon as possible. They can advise you on the best course of action.
  2. Your solicitor can help you request corrections from your healthcare provider: In many cases, simple errors can be corrected by contacting the healthcare provider directly. Your solicitor can guide you through this process or handle it on your behalf.
  3. If necessary, you can provide a written statement explaining any inaccuracies: If the healthcare provider is unwilling to amend the records, or if the process would take too long, you can provide a written statement detailing the inaccuracies. This statement can be included with your medical records when they’re submitted as part of your claim.

It’s important to note that challenging inaccuracies doesn’t mean trying to hide or alter unfavourable information. The goal is to ensure that your medical records accurately reflect your condition and treatment. Honest and accurate medical records are crucial for building a strong and credible personal injury claim.

Using Medical Records to Maximise Your Claim

Your medical records are not just a requirement for your claim; when used strategically, they can significantly strengthen your case and potentially increase your compensation. Your solicitor can use your medical records in several ways to maximise your claim:

  • Highlighting the severity and long-term impact of your injuries: Detailed medical records can paint a clear picture of how serious your injuries are and how they might affect you in the future.
  • Demonstrating the need for ongoing treatment or care: If your injuries require long-term or permanent care, your medical records can help justify claims for future medical expenses.
  • Showing how the injury has affected your ability to work: Medical records can provide evidence of how your injuries have impacted your capacity to work, supporting claims for lost earnings or reduced earning capacity.
  • Proving the necessity of any lifestyle adaptations you’ve had to make: If your injuries have required you to make changes to your home or daily routines, medical records can help justify these expenses as part of your claim.

By thoroughly analysing your medical records and presenting the information effectively, your solicitor can build a compelling case for the full compensation you deserve.

Frequently Asked Questions

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Comments & Questions

Read on for questions and advice about claiming...

I had revision surgery on lateral side of foot November 22, 2021, and my foot has never been the same – experiencing pain and nerve damage. I don’t think a nerve block was initially applied before procedure. Do I have a right to receive a medical report listing everything the surgeon did regarding this operation?

Ian Morris

You should be able to obtain the details of any treatment provided to you and access your medical records by contacting the relevant department within the NHS. If you feel that you have been the victim of clinical negligence, contact us so that one of our specialist clinical negligence compensation Solicitors can assess your potential claim and advise you further. We offer No Win No Fee services on clinical negligence and can make sure that your rights are upheld if appropriate.

Reply

Hi! I had accident in a taxi like rear passenger, I went in emergency then to the gp, after almost 4 years from accident I heard from my solicitor that my medical report is not the same which I done with his doctor, they emailed me the medical reports from gp and emergency, and I can see they wrote something else than I said, they did not stated all my pains, and in the emergency they wrote cheek pain , not the actually pains I told them, even that the car hit us from the back had high speed, they wrote the car hit us from behind was travelling with 20-30mph. Now because of them I am called dishonest and have to pay £6300 to the solicitor. What can I do in this case? Thank you!

Ian Morris

Have you spoken with your Solicitor regarding the mistakes made by the A&E/GP medics when noting your symptoms initially?

Andreea

Yes I told them that is not what I said in the emergency and gp.

Ian Morris

Your Solicitor should attempt to explain the discrepancies to the 3rd party and point out that these errors are not of your doing and are not due to fraud or wilful dishonesty.

You could also contact the NHS Medical records department to seek that they correct the entry and point out the problems that their mistake is causing you.

Andreea

I contact them and they said is nothing to do anymore, already is in the system

Ian Morris

Your Solicitor should be seeking to resolve this for you.

Andreea

Thank you for your help. I appreciate a lot

Reply

I had my medical almost 5 weeks ago and still havent heard anything… how long does it normally take to get your medical report so that you can see that your happy with it.

Ian Morris

You will likely receive correspondence from your Solicitor regarding the medical very soon. It is usually the case that a medical experts report will be with the claimants Solicitor after around 4 working weeks. The Solicitor will then review it and ask you to do the same – which will probably take them a week or so to get round to (given the order in which incoming post will be ranked). As such, you should have sight of the medical experts initial report within 4-6 weeks of the examination.

Reply

Hi I recently had 2 accidents in work within a year of each other. Both times I slipped on an unmarked wet surface. My latest accident left me with damaged ligaments for which I have to have surgery for.
The reason I am writing is because I am currently in the process of claiming compensation from my employer, my solicitor who is acting via my union has ask for release of my medical records back to my birth …I find this a bit extreme and rather intrusive ..can they do this?

Ian Morris

In short, yes. Whilst many people feel anxious about the release of medical history, it is important that the records are checked to see if there is any previous history of problems with the injured area that may impact on the claim. Your Solicitor is duty bound to maintain the utmost privacy and data protection regarding your medical records and the documents must be handled securely.

Reply

An accident occurred in September 2017.

How far back in years (as per protocol) is my GP legally allowed to forward to the courts pls.

Ian Morris

Your entire medical history can be considered when making a claim for personal injury – in that any previous medical issues relating to any area of injury claimed for that are listed on your medical records may be provided.

Reply

Ive called my insurance company and i asked will they be contacting my doctor and they said no … which im not happy about as how can they know exactly what pain and suffering i went threw. Also i was told from physiotherapy i have lumbar and cervical damage and the physiotherapy was organised threw my insurance so im hoping they swap notes as its been almost 5months when i had accident, and ive only just been for medical on monday and was seen for around 10 mins and just asked to turn my head from side to side and bend over … i dont understand how they can claim compensation from not seeing my injuries that i had … severe abdominal bruising, cut to arm and bruised knees and bruised collar bone and bruised bust .. then had under surface cycst where i had the bruising on abdominal area, all of this they cant see from looking at me almost 5 months later .

Ian Morris

If the medical assessment you were having was for ALL of the injuries sustained, it should last longer and be more thorough than the one you appear to have had. However, if there was just a query about one specific injury or range of movement, the process could be quicker.

You should certainly flag this up with the relevant person dealing with your claim. Do so in writing and demand written responses.

Reply

I was in a car crash and have just had a medical. I’ve taken pictures of my injuries throughout the weeks and was told to do this. However, nobody has asked to look at these pictures. So how can a medical be done for compensation, if they are not aware of how badly I was hurt just after the crash that happened in May 2022?

Ian Morris

The medical that you have had will have been conducted by a qualified medical professional with expertise in the type of injuries that you had sustained and that are noted within your claim. The medical expert will use various factors in the completion of their report including, a review of relevant medical records (including any x-rays or scan results) and treatment notes relating to your injuries/recovery, a conversation with you about the incident itself, your injuries and how the symptoms impacted you/still cause discomfort and if applicable, a physical examination regarding any ongoing symptomatic areas.

These factors will go in to the report that is completed and a prognosis of the recovery period or recovery amount will be made. You will then have an opportunity to review the report and agree or disagree with any aspects. Your Solicitor will then be able to obtain advice regarding an appropriate value to the injury element of your claim and discuss the same with you. The photographs you have could end up being useful if you need to further demonstrate severity of injury or discomfort to help increase any rejected offers.

Tracy

Thankyou this was very helpful, also do they take into consideration of having to have physiotherapy and the fact that i got shingles due to the trauma, this is all noted with my doctor. Will they contact my doctor for my notes .

Ian Morris

Any physiotherapy treatments should be taken in to account and if a causal link between the injuries sustained and shingles can be established, that may also be included.

Reply

I am unhappy with the medical report from a spinal specialist that I have had. The specialist reports that an annular tear that was found during an MRI scan was not caused by the car accident. My medical records from my GP and NHS physiotherapist from the date of the accident report pain in the exact area that the tear has occurred. I have no record of back pain previously on my medical records. My solicitor says to question the specialist will jeopardise my case. I am using a solicitor recommended by my car insurance company.

Ian Morris

Surely your Solicitor can ask the specialist to clarify why they do not believe that the tear in question is linked to the index incident? Seeking a medical experts report & prognosis is an essential part of the process of claiming personal injury compensation (as it is the medical experts report that forms the basis of injury value), there is always the risk that the contents of the report can be damaging to a claimant. In the case where an expert doesn’t provide a particularly supportive report, a claimant is somewhat stuck. Whilst you could seek a 2nd experts report, there is no requirement for a defendant to accept the 2nd report and there is no guarantee that it would differ from the first experts report either. Further, you would not be able to recover the cost of a 2nd report, whereas you can with the 1st report. As such, seeking clarification from the medical expert (bearing in mind your medical records should show that you have not sought treatment for any similar pain or issues previously) is the best course of action.

DAWN

Thank you for your response. I asked my solicitors to inform the expert that there was a detail incorrect on the report and asked the question how he had come to the conclusion regarding the annual tear when documentation and MRI confirmed the exact place I had reported the pain since the day of the accident, I was seen by a GP 4 days after the accident and have seen 3 medical experts since the accident, all 3 plus my own GP have agreed to soft tissue injury in the area. He has totally ignored the question and just changed the incorrect information, my solicitor has said we cannot do anything about this and he does not have to answer any questions put to him. The third party insurers have seen the 2 previous reports, all my GP reports and the MRI scan, will they have to take all this information into account when valuing the claim or just the latest one from the spine specialist?

Ian Morris

The insurers will have to consider the evidence set out in all medical reports received and reach a balanced point of view.

Reply

Hi I had my medical report back from my solicitor and it says I reversed the pump truck wich lost control is that implying that I lost control I am a bit confused as when I unloaded the pallet the ppt machine I was using shot back and trapped my arm between the ppt and metal racking .

Ian Morris

You should query this with your Solicitor to ensure that the report is read as saying that you lost control of the pump truck due to a fault with the pump truck and not that you simply lost control of it through human error.

Reply

I have preexisting anxiety and Ptsd which was exacerbated after a car accident whilst i was pregnant. The other party has admitted liability but are claiming that anxiety was preexisting and not a result of car accident. I saw a psychiatrist after my daughters birth to deal with my anxiety. My medical records make extensive reference to my anxiety but the car accident has not been documented. My psychiatrist and i spoke about this in detail…… How can i prove that the accident made my condition worse if medical notes dont reference it?

Ian Morris

Have you asked the Psychiatrist that you saw to provide written confirmation that you did raise the car accident with them?

Amy

I wasn’t aware that i could do this? I no longer see the psychiatrist so would I still be able to ask them?

Ian Morris

You can request this from the psychiatrist, but you may have to pay a fee for their time or a written report.

Reply

Me and my son had a car accident. My son has diagnosed ASD. I have received medical report and clearly my son’s condition is not taken into account. I do not agree with recovery time. Can I ask my solicitor to rewrite or add something to the report?

Ian Morris

Your Solicitor cannot re-write the report, but you can disagree with the contents and request that your Solicitor write to the expert in question to raise the issues you are not in agreement with and seek that they re-consider the report and the specific issues that may affect your Son given his diagnosed health condition. It could well be that the specialist in question has not taken that in to account or wasn’t provided with the evidence needed (formal diagnosis of the condition) to be able to include it in their report.

Reply

I had a medical assessment in May this year. I was happy with the report but advised not to settle, as it would be better to wait till 1 year post op which was Aug 2021 as if I was still in pain then, I probably would be for life. I was also told that Premex would need to get up to date hospital records. They have been chasing this since June when I gave them my consent to get the records. Why is it taking so long? Do I have a right to access my medical hospital records to forward myself to my solicitor? Would it effect my claim by doing so? Surely it shouldn’t take 4/5 months to get records?

Ian Morris

You’re right, it shouldn’t take such a long period to release your medical records and it usually doesn’t take this amount of time. Occasionally we do come across departments or that are painfully slow in acting on any request for patient information.

Anything you can do to help to speed up the process – by contacting your GP surgery and the medical records people to get the records sent to you or the medical company will only help your Solicitor to move things forward more quickly would be beneficial to you and your claim.

Reply

How far back does a solicitor deem a degenerative problem . My last complaint for the area which I have injured was over 10 years . Will that be seen as degenerative?? Also medical record from gp is missing a entry how do I chase that ??

Ian Morris

Whether an injury can be attributed to age degeneration, will be a matter for a medical expert to decide. Of course, if you have ever had a previous injury to the area that is now at the heart of your claim, you do need to disclose that – both to your Solicitor and to a medical expert when they assess you in order to be transparent and open. However, if your previous GP treatment was 10 years ago and was a ‘one off’ for a condition that was a short term injury or problem, it is unlikely that it will count against you.

Reply

My solicitor is now awaiting my medical report from the medical examiner as the defendant’s I have claimed against have admitted liability pending a medical. Once my solicitor receives the report and sends it off to them, what are the next steps they will take? Will it just be a case of negotiating a settlement payment or can they make me have another medical just to delay the process? Thank you

Ian Morris

When you the medical experts report is provided, your Solicitor will provide you with a copy and ask you to confirm whether you are happy with the contents. Assuming you are, the report will be handed to the defendants and they can then respond accordingly. Whilst they are allowed to seek a further report, this is unlikely and that can’t do it just to delay the process unduly. In most cases, once the medical report is received and agreed by both parties, the Solicitor and Defendant will begin discussing an appropriate settlement and move to get the case settled and closed.

Reply

I’m still trying to get an interim payment 5 months down the line from first requesting one.
The defence want my medical records before even considering an interim payment.
I had my medical 2 weeks ago for my claim but still waiting for the report.

My question is should I disclose my records now and if so would it be damaging to my case?

Ian Morris

Disclosing medical records is something that is a standard practice in personal injury claims. However, before disclosing them, you need to discuss this with your Solicitor.

Reply

Hello.
I ve been in A&E after accident at work. But nobody give me medical record. I have to ask A&E get record for claim accident at work?
Thank you

Ian Morris

You do not need to ask the Hospital or your GP for a copy of any report and you do not need one to make a claim, however you should make sure that your employer has an accident book record of the accident.

Reply

If a claimants court proceedings for a personal injury claim have begun but then they’re asked to provide gp records but do not wish to give them up due to mental health records can they pull out of their claim without any charges from their no win no fee solicitors?

Ian Morris

Failure to proceed or release medical history will be seen as wilful failure to cooperate and the claimant would be in breach of their Conditional Fee Agreement terms and conditions. This would force the Solicitor to have to pursue the claimant for costs.

Dee

Hello, my solicitors have asked for my full medical records. I do not want to disclose them and want out of my whole legal case! If I deny access can I pull out of my case without any legal charges?

Ian Morris

If you refuse to disclose your medical records, that will be seen as a failure to cooperate and as such, you would be in breach of the terms of the instructions you signed to get the Solicitors to act for you and you could face financial penalties for the costs your Solicitor has incurred in handling your claim.

Why would you not wish to disclose your medical records? Whilst they clearly contact personal and private information, the records will only be viewed in confidence by your Solicitor and the medical experts handling the claim. The information will not be publicised or shared so you really have nothing to fear.

Reply

I misread my medical report and sent it back to my solicitor by mistake. I did not sign that I read and understood the medical report, my solicitor instead of sending me back the full medical report to read and sign again she took just one page from the report and sent it back to me to sign. There are things in that i didn’t read about after she submit my claims, then she says that I can’t say my injury happened because of the accident. How can I go different about it i haven’t accepted the offer yet?

Ian Morris

Have you spoken to your Solicitor about the error that their handling of this part of your claim has caused? It would appear that your Solicitor has at least contributed to a potential undermining of your claim through negligence. With that in mind, you should discuss this with the Solicitor and if they are unwilling to do anything about it, formally complain to the firm.

Reply

I was involved in slipping injury where I injured both toe thumbs on the stair cases, one dead nail and another partly dead. I did go to my GP and was told that nails r dead. I had all evidences photos and videos of the hotel I was injured. The hotel has accepted liability. Why is the solicitor asking for my medical notes? Do I need to see another independent doctor to assess my injury/ies even tho I already had it in my medical notes?

Ian Morris

The medical records will show the dates of attendance and the injuries presented/treatment given at the time. A medical assessment is needed to ascertain the level of recovery or ongoing problems in order that an appropriate valuation can be attached to your claim.

Reply

My solicitor has stated my GP will not respond to a written request for my medical records. what can I do to help get my medical records?

Ian Morris

Obtaining medical records from a GP surgery for the purposes of a personal injury claim should be an easy process, but on many occasions, GP surgeries fail to release the medical records in a timely fashion and take some chasing and repeated requests to pass the information over! This is quite a problem at the moment, but the GP surgeries have a duty to make sure that medical records are passed to people with the authority to view them.

One thing we have found to help greatly, is for the claimant to make contact with their surgery and speak nicely with the reception team or GP and express the need for the release to be made.

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