Medical Records as Crucial Evidence in a Personal Injury Case

May 3, 2023
by We can Help Law

Medical Records are a Vital Piece of the Puzzle in a Personal Injury Case

Medical Records as Crucial Evidence in a Personal Injury Case in New Jersey

Medical records are crucial in a personal injury case because they document the extent and severity of the injuries sustained by the plaintiff. These records provide objective evidence of the injuries, their diagnosis, and treatment, which are essential for establishing the damages and compensation owed to the plaintiff.

Medical records can be used to demonstrate the causation of the injuries, i.e., that the defendant’s negligence or wrongdoing caused the injuries. They can also be used to prove the severity and duration of the injuries, the extent of the medical treatment required, and the future medical expenses the plaintiff may incur.

Moreover, medical records can be used to counter any allegations made by the defendant regarding the plaintiff’s injuries. For example, if the defendant claims that the plaintiff’s injuries are not severe, medical records can provide objective evidence to the contrary.

The Essentials of Healthcare Documentation after You Have been Injured

Overall, medical records are an essential source of information in a personal injury claim. They can help establish liability, damages, and compensation owed to the plaintiff. If you have been injured in an accident, seeking medical attention and keeping detailed treatment records to support your claim is essential.

Key Information in Your Medical Records That Can Make a Difference in a Personal Injury Claim

To bolster your personal injury claim, reviewing medical records is key in identifying crucial pieces of information necessary for proving your case. Important data includes diagnosis notes signifying injury type and severity sustained by the plaintiff, which can help construct a more accurate evaluation for proper planning within legal proceedings.

Recorded treatment details such as medication prescriptions, surgical operations conducted, and physical therapy serve as invaluable sources when figuring out treatment duration and expenses, giving a better view of patient progress. The expected prognoses provide potential factors leading to future risks and expenses, which could lead to functional impairments.

Medical records can also serve as a platform for expert witnesses such as trauma physicians, orthopedists, neurologists, and internal medicine specialists who can explain in detail the original injury, treatment, and the expected outcome in terms of therapy and medications, as well as the quality of life that is expected.

Steps to Access Your Medical Records in NJ

There's Critical Information in Your Medical Records When it Comes to a Personal Injury Claim in Monmouth County, NJ

Patients under the jurisdiction of New Jersey’s Patient Access to Health Record Act can utilize this law to access their medical records. You fill out a form that includes your name, birthdate, phone number, and mailing address. You can request to have them sent by mail or electronically. You also may need to send a copy of your driver’s license or other government identification for validation purposes.
You are required to receive the requested information within 30 days. There may be a small fee if the records are in hard copy. Some healthcare facilities prefer that former patients come to the hospital or clinic to look at the records in person. This is mostly done in smaller facilities or where there is a concern regarding HIPPA and confidentiality issues.

Be Aware of Your Rights Regarding Medical Records

As a patient, you have certain rights about your medical records. These rights are protected by federal and state laws, including the Health Insurance Portability and Accountability Act (HIPAA) and the New Jersey Patient Access to Health Records Act.

You have the right to access and obtain a copy of your medical records from your healthcare provider or facility within a reasonable timeframe. You can request that your medical records be corrected if you believe they are inaccurate or incomplete. Privacy laws protect your medical records, and your healthcare provider or facility must take steps to protect the confidentiality of your documents. You have the power to know how your healthcare provider or facility uses and shares your medical records. You also have a say as to who has access to your documents.

Can Insurance Companies Access the Information in My Medical Records?

The insurance company can request your medical records for several reasons. Be aware that you are only required to send them the information related to your personal injury claim. They will use the information provided in your medical records to substantiate the severity of your injuries, the treatment you were given and ensure all procedures were related to the injuries you succumbed to in the accident.

If you have chronic illnesses not exacerbated by your injuries, you are not required to give the insurance company total access to your medical records. For example, having asthma or Raynaud’s syndrome will not affect an accident with resulting head trauma.

Sometimes, insurance companies will encourage you to allow them full access to your medical records by signing a waiver. You never want to give them more than what is pertinent to the incident at hand. All test results, such as x-rays, MRI or CAT scans, diagnosis, plan of treatment, prognosis, proof of the treatment you are receiving, will need in the future, and any possible extended or permanent disabilities resulting from the accident should be included. Before sharing any information with the insurance company, seek the advice of your attorney.

Rules on the Admission of Evidence

The admission and application of evidence in a court of law are governed by a set of legal principles known as the rules of evidence. These rules are intended to guarantee the validity, applicability, and fairness of the evidence offered during a trial.

These rules vary depending on the jurisdiction and the type of court. However, some common principles apply to most legal systems. For example, the evidence must be relevant to the issues in the case, reliable, and obtained legally. Hearsay evidence, unless an exemption exists, a statement made outside of court that is presented to prove the veracity of the matter alleged is generally inadmissible.

The rules of evidence are essential to ensure that the trial process is fair and accurate. They help to prevent the admission of unreliable or irrelevant evidence that may prejudice the outcome of a case. By ensuring that only admissible evidence is presented, the rules of evidence help to promote the truth-seeking function of the court.

Applying the Rules of Evidence to Medical Documentation in NJ

Adele Konop and Richard Konop, her husband, sued Dr. Ellen J. Rosen in a malpractice case. In the lower court, a judge granted the defendant a summary judgment when it was decided that a notation in Adele’s medical record was made by someone other than Dr. Rosen. It was said that Dr. Rosen verbally relayed the note to another physician, who then recorded it in the patient’s file. The judge said the report and the notation were hearsay, and a summary judgment was entered for Dr. Rosen.

The Konops appealed, and the Appellate Division decided the review would be de novo. This is when the case is looked at “anew”. Usually, appeals are based on a missed law or poor interpretation, but this appeal requires a new hearing. The de novo judicial review is a review of the lower court wherein the appellate court examines the issue from the beginning rather than focusing on the lower court’s decision.

The panel decided that if a jury determined by a preponderance of the evidence that the defendant allegedly made the statement that served as the basis for the notation, then the notation would be allowed. To qualify under this exception, the plaintiff needed to demonstrate that the notation accurately reflected a statement made by the defendant.

Questions About Your Medical Records in a Personal Injury Case in NJ? Call our Monmouth County Law Office Today

A personal injury attorney from our firm can help you get all necessary medical records and decide which records should be shared with the insurance company. We can interview witnesses and map out a solid strategy to get you compensation for your injuries.

Our experienced attorneys are excellent negotiators with all the necessary knowledge to go to court in Holmdel, Howell, Asbury Park, Freehold, Tinton Falls, Brick, Neptune, Toms River, Jackson, Marlboro, Monmouth County, Ocean County, and across the state of New Jersey. The insurance companies are not interested in your health. They are motivated by how much money they can save by giving you the lowest settlement possible. We aim to protect your rights by getting the full amount of damages you are entitled to after an accident.

Time is of the essence. Call our office at (732) 303-7857 or contact us online for your free consultation with an attorney on our team.