MEDICAL RECORDS: YOU MAKE HISTORY

One of the best pieces of advice I’ve heard in 20 years of the practice of personal injury and workers’ compensation law was this: “”Your clients should never tell their doctor right away that they’re feeling better…even if they are.”” The reason isn’t to lie to your doctor, or to hide something, or to make your claim better. The reason is that doctors take a written history of what you say…and doctors often fail to take a complete history. They very often only write down the first thing you say. If you go to your doctor and say, “”Doc I’m feeling better.”” but later mention that you’re still having problems with your back or legs or hands…and that the problems are causing you considerable pain…the only thing the doctor will write down is that you’ve improved. So, the best approach is the straightforward truth. When asked how you feel, be specific. Tell the doctor:
1. What your pain level is with activity and at rest.
2. What your specific symptoms are (e.g. hands are numb, back spasms, legs give out..)
3. How well your medication is working.
4. Whether you have any new symptoms. For instance, people who injure one knee often start to limp or walk with an “”altered gait.”” This change of motions often causes pain or injury to other body parts such as the knee, hip or back.
Finally, go to a store and buy an inexpensive notepad and keep your own log of every doctor visit. Note each visit, what was discussed, what the treatment plan was/is, whether the doctor kept you off work, what specific history you gave the doctor, etc. Make the notes the same day as the visit. If you really want to help your case then keep a log of how you feel each day and be specific about what you notice about yourself. Do not include any conversations or comments between you and your lawyer. The sole purpose of the log is to make your own medical history. You can refer to the log to help you remember when you give a deposition or testify at trial.