The Effect of Medical Records in Litigation

Some say that there are three sides to every story – your side, their side, and the truth. In personal injury litigation, there are four sides to the story – what the Plaintiff says, what the Defendant says, the truth….and what the medical records say.

In every day life your medical records are important for a multitude of reasons. First and foremost, the recordings of your health history have a direct effect on the medical treatment you may receive. New doctors and specialists typically review your medical history to aid them in their treatment/diagnoses. Your records can also affect your ability to obtain health and life insurance, as well as the rate you receive for that insurance.

When litigation enters the picture, there is an increased significance in the importance of your medical records. The information contained in the records, as well as any information that is not contained in your medical records is essential to proving the elements of many personal injury and pharmaceutical claims. For example, in a pharmaceutical case, where a person took a medication and suffered an injury as a result of taking the drug, your medical and pharmacy records will be closely reviewed by both your attorney and the attorney representing the drug company; these records may even be shown to the jury during trial.

There are several things that can be gleamed from your records during a lawsuit. Generally, they will speak to the status of your health prior to the incident that concerns the lawsuit. They can also provide proof that you suffered the claimed injury and that you were taking the medication consistently. Consider the pharmaceutical case described above. What if that injured patient didn’t fill their prescriptions at a pharmacy but, instead, got samples from their doctor and that doctor never documented the samples given – it is more difficult to prove to a jury that the injured patient was on the drug and took it consistently.

While you can’t control all of the information your doctor puts in your records, you can take certain steps to ensure that your records are well managed:

(1) Provide accurate information to your doctor to help ensure that your records are free of errors. Important information includes current medications, new or continued symptoms and medications that you have stopped taking since your last visit.

(2) If you stop seeing a doctor, make sure that you obtain a copy of the records s/he maintained for you. These records should also be provided to your new doctor.

(3) When getting new prescriptions, request that the name of the medication and the dosage be written in your chart. If samples were provided, ask that it be documented so you can remember when you started taking the medicine.