Until I started working as a personal injury attorney I was probably like most people who go to the doctor. I told him my problems, he checked me out and wrote a prescription. Sometimes he would tell me what his diagnosis was, sometimes I already had a good idea. I never actually saw his “chart” or looked at any of my lab reports or saw his dictation.
Doctor’s dictation is rarely if ever seen by their patients. Patients rarely ever know what is in their charts until they or their attorney gets a copy and goes over it. Even if they could read the charts fewer still would know enough medicine to understand what the doctor has dictated.
I have to read my clients charts frequently because my job is to explain to an insurance adjuster what the charts mean as far as injuries is concerned. In looking at charts I see dictation by doctors who are on the fence. They dictate that the motor vehicle accident of October 29, 2010 may have caused the injuries, or that the pain could be due to problems which started after the crash, or that the problems followed the crash.
All of these types of comments are weasel words that waste my time. I need a doctor to say the accident probably caused the injuries or substantially contributed to causing the injuries. That pushes the button of legal causation. In other words it is not enough that you fell down in a store and hit your head, or were rear ended at a red light and have low back pain now. The doctor has to go on record and say that your head injuries or back pain are probably due to the slip and fall or probably due to the rear end collision.
Causation does not make much of a difference when the only issue is whether the care is necessary and the doctor gets paid. Like when you get sent to have an MRI, the insurance company which will pay the bill just wants to make sure there is a prescription. But, some insurance companies need to know why? That is where the issue of legal cause comes in to play. Why do you have complaints about your head? Is it because of your diabetes, or maybe an ulcer acting up, or you had a stroke, or your bad back is acting up? Or did the slip and fall or other accident cause it?
I live in a small town called Palm Coast. The doctors here are not really geared up for trauma care like they are in bigger cities. They often do not GET IT when it comes to writing a good medical report for a legal case. They are in the position to do tremendous help by going to bat for you, or tremendous harm by glossing over the WHY question. When they shirk their duty to be an objective witness through their records you get hurt because your case is weakened or destroyed. Doctors have an ethical obligation to be a witness through their records but often side step that responsibility.
Having a good lawyer includes having one who knows what good medical records should contain, so you do not wind up going to court with a weak case that should have settled because your doctor did not go to bat for you.