The importance of medical documentation in personal injury cases

VIDEO TRANSCRIPT:  Hi, this is Robert Mansour. I'm a lawyer in the Los Angeles area. One of my areas of practice is personal injury. I wanted to spend a few minutes with you on this brief video to talk to you about things you need to keep in mind when treating with doctors and physical therapists after your personal injury case.

What you want to make sure you understand is that the insurance companies are going to be evaluating your case partly on what's called the diagnostic codes, which means that what the doctor writes down as your diagnosis is going to be considered by the insurance adjuster.

That's why when you go to the doctor you have to tell the doctor everything that's bothering you and with great specificity. So you can't just go in there and say, “Oh, my neck hurts.” Well, what is it exactly? “Oh, I have radiating pain into my shoulder and between my shoulder blades or my middle back, my upper back and my lower back hurt me” rather than oh, my back hurts me. What is it exactly that you're feeling? What are your symptoms? The doctor has to write all this stuff down. It's transferred into a diagnostic code that is written in your medical records.

The reason this is important is because if something is not in your medical records it's like it never happened. So, if there's a diagnostic code that is missing or some complaints that you have that are not documented in those medical records, then it's like it never happened. The insurance company will not consider it. You see, the insurance companies are using software more than ever to analyze their cases. So a lot of major insurance companies now are using software products in order to evaluate these cases.

What they do is they'll type in your age, where you live. They'll type in all the diagnostic codes. They'll type in all the treatment codes, any treatment that you received from any place. Also, they look in the medical records to see what kind of complaints you had. This is why it's very important to indicate in your intake forms when you go to the doctor. When you talk to the doctor, every time you see the doctor, you've got to mention what you're going through, what you're feeling.

I had a client. She called me and she said, “I'm having a really hard time at work. I'm having concentration issues and also my back is killing me when I drive for more than half an hour.” I told her, “You need to tell the doctors about this. It needs to be written in your records.” The reason once again, if it's not in your records it's like it never happened.

So, once again, please keep in mind that you're got to tell the doctor everything that's going on. Those diagnostic codes are very important. The way the accident has affected your daily life you want to make sure you tell the doctors and the physical therapists about that. You know, every time you go to the doctor they ask you. They say, “How you feeling?” You go to the physical therapist, “What's going on? How are you feeling? What's been going on since the last time we saw you?”

That's where you tell them with great specificity what's going on so they can document it. Of course, if it's not documented then it's not going to end up in the software and the software will not analyze your case and the insurance adjuster will just treat it like it never occurred.

I hope you found this video helpful. My name is Robert Mansour, and thank you very much for visiting today. If you want to learn more about my practice, you can visit www.valencialawyer.com, or you can call my office at 661-414-7100. Thank you very much for watching this video.