The Alabama Court of Civil Appeals has released an opinion dealing with medical records in relation to on the job injuries. This opinion over ruled a trial court’s determination that a worker suffer an on the job injury. This is unusual because the Appellate Courts generally recognize that a trial court is the best position to see,hear and evaluate a witness. The Court based its opinion in large measure on the medical records of the injured worker which did not reflect that the treatment was the result on an on the job injury.
The medical record in the personal on the job injury reflected that the injury preceded the date given by the worker. The worker lost his right to have his medical bills paid and compensation for his work injuries because of the disputed accuracy of the injured workers medical records.
Jurors, like judges, want to see consistency in the medical records. With the many cases we see here at McCutcheon and Hamner, these are two (2) major problems we encounter with medical record keeping.
First, doctors and nurses are busy. The demand for their time is relentless. The reason doctors and nurses are doctors and nurses is to help give comfort, aid, and appropriate medical treatment for the healing of their patients. People in the medical professions want to treat illness and injuries. The ability for them to understand and write down how an injury occurred is limited by the patient’s ability to state when, where and how the accident or injury happened. Understandably, when someone is hurt that is more important than how they were hurt. Understandably, when someone is hurt their ability to give an accurate history of that injury is limited. Too bad that defense lawyers prey upon this fact every time they can.
Second, there is a new legal mandate for electronic medical records. This causes doctors and nurses to be more prone to check a box that is already provided than to write down the ins and out of how and accident or injury occurred. You end up with a medical record that focuses on the major complaint but may leave out secondary complaints that prove to be more persistent than the original complaint. The fact is that if you are bleeding, that is more important at the time than the fact that your shoulder hurts. However, if you later need shoulder surgery be prepared to be called a liar by the insurance company lawyer.
If you are hurt or injured through someone’s negligence or through an on the job accident or injury, make certain that your medical records are accurate. If you are in doubt, call McCutcheon and Hamner (or another law firm that practices personal injury litigation) and we will talk with you about your workplace accident injury case at no charge. We will advise you on whether you have a case and whether we would take it and if not, why not. If we do take your work place accident injury case, we will obtain your medical records and call to your attention any potential errors that may exist so that problems may be avoided.