Your medical records in an injury claim

Medical records are the evidence of an injury. They show what happened, when, how it was treated, and how it changed over time. Because the other side reads them just as closely as your lawyer does, it helps to know what is in them and how they move.

It is general information, not legal advice, and it is not medical advice.

The parts of a record

• History and physical. The intake account of the injury and the first examination.
• Progress notes. Each follow-up visit — the classic format records what you report, what the exam shows, the assessment, and the plan.
• Imaging and radiology reports. The films themselves and the radiologist's written reading. The report language matters — "no acute abnormality" is not the same as "normal."
• Operative reports. A surgeon's detailed account of a procedure.
• Therapy notes. Physical, occupational, and mental-health treatment, often with measured progress.
• Discharge summaries. A summary of a hospital stay and the instructions on leaving.
• Diagnostic and procedure codes. Standardized codes attached to each visit — covered on medical bills and the EOB.

How records are requested and released

Records are protected by federal and state privacy law and are released only with a signed authorization or a valid legal process. The authorization names the provider, the recipient, the records covered, the time period, and an expiration date. A provider may charge a reasonable fee for copies and generally must respond within the time the law allows. The scope of an authorization is the thing to read: a form covering "any and all" records from "any" provider is very broad.

Putting your condition at issue

Making a claim for a physical injury waives privacy for the records that relate to that injury. Claiming ongoing or permanent effects, or a psychological injury, widens what is relevant, because the other side is entitled to test whether an earlier condition explains some of it. A pre-existing condition does not defeat a claim — if the accident made it worse, that worsening is compensable — but the prior records will be part of the picture.

Common problems

• Missing records. A provider closed, records were purged, or a visit was never documented. Request early.
• Transcription and copy-paste errors. Notes carried forward from a prior visit that no longer fit, wrong side noted, or a symptom mislabeled.
• Understated histories. A busy visit where you mentioned several problems and only one made the note.
• Gaps. A period with no treatment, which the defense reads as recovery unless there is a documented reason.

Retention

California sets minimum retention periods — generally at least seven years for adults after the last encounter, and longer for minors. Hospitals and some records have their own rules. The safe course is to obtain and keep copies of the important records yourself.

Common questions

Does the insurance company get all my medical records?

Not automatically. Records are released with your written authorization. Once you make a claim for injury, the records relevant to that injury become discoverable, and if you claim a long-term or psychological injury, some earlier records may be too.

Should I sign the authorization the adjuster sent me?

Read its scope first. A broad authorization can let an insurer pull your entire lifetime history from every provider. A narrower one limited to the injury and a reasonable time period is common. Whether to sign a specific form is a question for a lawyer.

There is an error in my records. What can I do?

You have a right to request an amendment to your medical record. The provider can accept the correction or add your statement of disagreement to the file. The original entry usually stays, with the correction noted.

How long do providers keep records?

California generally requires adult records to be kept for at least seven years after the last visit, and a minor's records until they are 19 or seven years after the last visit, whichever is longer. Request important records early rather than assuming they will be there later.