Medical Records & Your Workers Comp Case: What You Need to Know

Why Medical Records Matter So Much

Insurance companies make decisions based primarily on what's written in your medical records. Not what you tell them. Not what your attorney argues. What the medical documentation shows.

Medical records establish:

• Causation: That your injury happened at work
• Severity: How serious your condition is
• Treatment needs: What care you require
• Work restrictions: What you can and cannot do
• Disability level: Your permanent impairment rating
• Consistency: Whether your reported symptoms are believable

Without proper documentation, even legitimate injuries get denied. With thorough records, claims proceed more smoothly and settlements increase.

The Initial Medical Visit: Setting the Stage

Your first medical visit after a work injury is critically important. What gets documented at this appointment follows your case forever.

What Should Be Documented

• How the injury occurred: Detailed description of the accident or exposure
• That it happened at work: Clear statement connecting the injury to your job
• Your symptoms: Every complaint, not just the primary one
• Physical findings: Objective observations by the doctor
• Initial diagnosis: What the doctor believes is wrong
• Treatment plan: Recommended care going forward
• Work status: Whether you can work and with what restrictions

Common Mistakes at the First Visit

• Minimizing symptoms: Saying "it's not that bad" when you're actually in significant pain
• Forgetting to mention body parts: Failing to report neck pain when your primary complaint is your shoulder
• Unclear work connection: Not specifying that the injury happened on the job
• Incomplete history: Forgetting to mention prior injuries to the same body part

The Danger of Gaps in Treatment

One of the most damaging things you can do to your workers' comp case is stopping treatment and then resuming later. Insurance companies seize on treatment gaps to argue:

• You must have recovered (otherwise you would have sought care)
• Current symptoms are from something else that happened during the gap
• Your condition isn't as serious as you claim
• You're exaggerating for settlement purposes

Why Gaps Happen

Injured workers stop treatment for many legitimate reasons:

• Feeling better temporarily: Symptoms improve but haven't fully resolved
• Work demands: Can't take time off for appointments
• Insurance delays: Authorization problems interrupt care
• Transportation issues: Can't get to appointments
• Frustration with the process: Dealing with workers' comp is exhausting
• Thinking you can push through: Trying to ignore symptoms

How to Avoid Treatment Gaps

• Keep all scheduled appointments
• If you must cancel, reschedule immediately
• If you feel better, still attend follow-ups to document improvement
• When insurance creates delays, document your attempts to get treatment
• If you can't attend, call the doctor's office to explain why

Explaining Gaps That Already Exist

If you already have a treatment gap, document the reason:

• Tell your doctor why you didn't come in during the gap
• Request that the explanation be noted in your records
• Gather evidence supporting your explanation (work schedules, insurance denial letters, etc.)

Consistency Is Everything

Insurance adjusters and their lawyers scrutinize your records looking for inconsistencies. Any variation in your story raises credibility questions.

Types of Inconsistencies That Hurt Cases

• How the accident happened: Different versions in different records
• Symptom descriptions: Varying reports of pain location, intensity, or character
• Activity levels: Telling one doctor you can't lift anything but another that you can lift light objects
• Prior injuries: Mentioning old injuries to some providers but not others
• Timeline discrepancies: Dates that don't match across records

How Inconsistencies Happen

Usually, inconsistencies aren't lies, they're communication problems:

• Doctor recorded what you said incorrectly
• You described things differently based on how questions were asked
• Symptoms genuinely vary day to day
• You forgot details and filled in differently at different times
• Translation issues if English isn't your first language

Maintaining Consistency

• Write it down: Keep a personal record of what happened and refer to it before appointments
• Review your records: Ask for copies and check accuracy
• Correct errors promptly: If a record is wrong, request a correction
• Be precise: Instead of "my back hurts," say "I have constant aching in my lower back that gets worse when I sit for more than 20 minutes"
• Use ranges when appropriate: "My pain is usually between 5 and 8 out of 10, depending on my activity level"

What Insurance Companies Look For in Records

Understanding what adjusters focus on helps you ensure proper documentation:

Objective Findings vs. Subjective Complaints

Insurance companies give more weight to things doctors can measure and observe (objective findings) than to what you report (subjective complaints). Objective findings include:

• Range of motion measurements
• MRI and X-ray results
• Muscle atrophy
• Reflexes and neurological tests
• Spasm palpable by the doctor

Mechanism of Injury

Does the described accident match the claimed injuries? Insurers question whether a "minor slip" could really cause a herniated disc.

Pre-existing Conditions

Any prior treatment to the injured body part gets scrutinized. They'll argue your current condition pre-dates the work injury.

Red Flag Phrases

Insurance companies train adjusters to look for certain phrases:

• "Patient states..." followed by something inconsistent with other records
• "Symptom magnification" or "possible malingering"
• "Findings inconsistent with reported mechanism"
• "Non-physiologic distribution of symptoms"
• "Patient did not appear to be in distress"

Your Rights Regarding Medical Records

California law protects your access to and control over your medical records:

Right to Obtain Copies

You can request copies of all your medical records. Providers can charge reasonable copying fees.

Right to Request Amendments

If records contain errors, you can request corrections. The provider doesn't have to agree, but must note your request in the file.

Right to Restrict Access

With some limitations, you can restrict who sees your records. However, in workers' comp cases, you generally must provide records relevant to your claimed injury.

What You Must Provide in Workers' Comp

Insurance companies can access records related to your injury and pre-existing conditions affecting the same body parts. They cannot access unrelated medical history.

Communicating Effectively with Your Doctor

Your relationship with your treating doctor directly impacts your case.

Before Each Appointment

• Write down symptoms you've experienced since the last visit
• Note activities that make symptoms better or worse
• List questions you want to ask
• Bring copies of any records from other providers

During the Appointment

• Be honest and complete about symptoms
• Describe your worst days, not just how you feel that moment
• Explain how the injury affects daily activities
• Ask the doctor to document your work restrictions clearly
• Confirm the doctor is noting that this is a work-related injury

After the Appointment

• Request a copy of the visit notes
• Review for accuracy
• Request corrections if needed
• Follow treatment recommendations

Common Documentation Problems and Solutions

Problem: Doctor Won't Support Work Restrictions

Solution: You may need a second opinion from a doctor who better understands your condition. Your attorney can help you find appropriate physicians.

Problem: Records Don't Reflect Your Symptoms Accurately

Solution: Discuss this with your doctor at the next visit. Be more specific about your complaints. Request amendments to inaccurate records.

Problem: Prior Records Show Pre-existing Problems

Solution: Don't hide this. Your doctor needs to document how the work injury aggravated or accelerated the pre-existing condition.

Problem: Emergency Room Records Are Incomplete

Solution: ER staff often document briefly. Follow up with your treating doctor to establish a complete record of all injuries and symptoms.

Problem: Different Doctors Have Conflicting Opinions

Solution: Your attorney will help determine which opinions best support your case and how to address conflicting views.

Special Documentation Considerations

Mental Health and Psychiatric Injuries

Psychological injuries require specialized documentation. Seeing a mental health professional who understands workers' comp is essential. They must document the connection between your work and your mental health condition.

Cumulative Trauma Injuries

Injuries that develop over time (like carpal tunnel or chronic back pain) require documentation showing progressive worsening related to work activities. A sudden claim after years without complaints raises suspicion.

Multiple Body Parts

Each affected body part needs documentation. Don't let minor complaints go unrecorded because you're focused on the primary injury.

Frequently Asked Questions

Why Legal Representation Matters

Medical record issues can derail even legitimate claims. An experienced workers' comp attorney helps by:

• Obtaining all relevant records from providers
• Identifying problems before they hurt your case
• Guiding you on how to communicate with doctors
• Connecting you with physicians who understand workers' comp
• Challenging inaccurate or biased documentation
• Explaining gaps and inconsistencies effectively
• Ensuring proper documentation of all injuries and limitations

We work on contingency. You pay nothing unless we win. Consultations are free and confidential.

Protect Your Case with Proper Documentation

Your medical records tell the story of your injury. Make sure that story is accurate, complete, and consistent. Don't let documentation problems cost you the benefits you deserve.

If you have concerns about your medical records or need help ensuring proper documentation for your workers' comp case, contact us today.