Are Medical Records Important in my Workers Comp Case?

Are Medical Records Important in my Workers Comp Case?  Yes, they are very important. Let’s discuss why. First and foremost, medical records are used by me to determine if we have a prima facie (first look) case to file a claim. That means, do the medical records document a work-related injury.

Why else are medical records important?

Your medical records should include an injury description, or a history, that you provide the doctor. More on that below. Your doctor may also make note if there are any pre-existing conditions that are relevant to the injury. Remember, you must disclose any and the fact that you may have a pre-existing condition, is NOT a bar to workers compensation benefits. You can read more about that here. Medical records help sustain the burden of proof an injured worker has in proving a work injury. They are also extremely important for the filing of a review petition to perhaps expand the injury description due to unpaid medical bills.

Medical records are also quite important for determining the injury description, whether the injured worker has work restrictions or is completely disabled from work, what physical examination findings are present, and finally what further treatment is recommended. What a doctor documents is critical as well.

Who reviews medical records in my case?

I, as your attorney, will of course review them. We also frequently update those records to ensure we have the least medical records.  The attorney for your employer/insurance carrier will also review your medical records ongoing. They will send your medical records to the independent medical examination doctor to review and include in their report. Additionally, the insurance adjuster is also likely reviewing your medical records frequently to determine medical status and work status.

If your case is expected to be a closed period (less than 52 weeks of work disability), your medical records may become the actual medical evidence. You can read our article form yesterday about that.

How can I help keep medical records clear?

It is critically important that you tell your medical providers about the work injury. Don’t assume they know, because they do not. What should you tell them? Easy answer is to tell them how you were injured. Explain to the doctor in detail exactly what happen that caused your injury. For example, if you were lifting something, tell the doctor what you were lifting and how much you though it weighed. What happened when you lifted? Where did you feel the pain? Be descriptive, but not embellishing.

Make sure you tell the doctor about ALL of your symptoms. Best way to explain this is an example. Let’s assume you were injured at work, fell, and hurt your right ankle and low back. Your right ankle is by far worse and extremely painful. That is what you are most focused on at the time of the injury. Be sure to tell the doctor about your back as well, even though that is not the predominant concern at the moment. The back may cause issues, worsen, and become a problem a few months down the road. However, if you failed to even mention it may look skeptical and can cause a problem with medical treatment being paid by the insurance carrier.

Workers’ compensation is quite complex and can often lead to complicated litigation. Medical records are critical in proving your case. Mooney Law has extensive, proven, and trusted legal representation for injured workers throughout Pennsylvania and Maryland. Call us right after an injury occurs so we can help guide your case. Our workers’ compensation consultations are always FREE. Call today at 717-200-HELP or 717-632-4656. You can also email us for a consultation at or visit our website and complete the form.

Mark Buterbaugh

Attorney representing injured workers and Social Security Disability clients in Pennsylvania and Maryland.