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The Importance of Medical Documentation in a Personal Injury Claim

When bringing a personal injury claim, a crucial element is that of gathering evidence, such as medical documentation. This will include all copies of medical records that are related to your injuries, including doctor’s notes, test results and treatment plans. Your medical records are significant in setting out your case.

As the Claimant and the individual bringing the claim, medical records are needed to support your version of events. In order for a personal injury claim to succeed, the records need to establish that the injuries claimed were sustained as a direct cause of the accident. If they do not, the claim is likely to fail, as this aspect cannot be proven.


Medical documentation assists with establishing exactly what injuries were sustained; the severity of your injuries, how they were sustained and any future complications that may arise from the injuries.

Injuries are not limited to just physical injuries. You may also be able to claim for psychological injuries sustained as a direct result of the accident. This will also be set out in your medical records, if these are not reported then it may be difficult to prove such symptoms developed as a direct result of the accident.

It is important to bear this in mind when reporting your injuries to your solicitor. Any inconsistencies will be picked up in your medical records, which can then lead to having a negative impact on your claim.

What if I already suffer from pre-existing injuries?

As a Claimant you are obliged to disclose any pre-existing injuries and relevant medical history, as these could potentially affect your claim. As the Claimant we have to be able to prove that the injuries you are suffering with are a direct result of the accident that you are claiming for.

In certain circumstances, you may already suffer with an injury however, due to the accident this has become exacerbated. If this is the case, then you may be able to claim for the period of exacerbation of your injuries, however this will need to be determined by a medical expert.

It is important to be honest about your injuries and past medical history, as this could affect your claim.

Ongoing Symptoms

In some personal injury matters, you may require ongoing care and treatment for the injuries sustained. Your medical records will be able to assist with this, as well as gathering expert reports to identify your future needs.

If your medical records reference ongoing pain and suffering, due to the accident, it is likely that a medical expert will also make this conclusion within their report. In turn, they are more likely to suggest treatment options and the costs of those options. This information can then be used to assess your claim, and may affect the amount of compensation that you receive.

Calculating Compensation

Following an accident, you may not be able to go back to work for a period of time, require care and assistance from family and friends, and require future treatment. All of these aspects will be considered when calculating the value of your claim.

Your medical records will be able to assist your solicitor in determining the valuation of your claim. You records will take into account:

-          The severity of your injuries

-          If you are fit to work

-          Any medical expenses

-          Costs of treatment

-          Medication

-          Rehabilitation

-          Any future costs or losses

There are various aspects of your medical records that will assist determining what damages may be recoverable as a result of your injuries. Therefore, they play a significant role in being able to prove your claim, and evaluating your compensation.