Medical Record Omissions

Posted by Scott A. Staples | Apr 07, 2020

When we represent clients in personal injury cases there are any number of things that attorneys for insurers can try to use to derail us, to cast doubt on the truthfulness of our clients. Some, although not enormous bombshells in a case, are problematic and come up repeatedly. They are innocent, but made to look otherwise. I'll discuss one briefly today.

I can't count how many times a defense attorney has made a huge deal of the fact that a client's medical record of a doctor visit, close in time to the injury, fails to mention the accident and injury. This happens for a variety of reasons. Sometimes it's out of our client's control- the client tells the doctor or other clinician about the problems they are having from their injury event, but the record simply fails to reflect that.

But just as often I ask a client if they know why the record fails to mention the accident and injuries- usually major events in their life- and they tell me they purposefully neglected to discuss it with their doctor because they were there for another issue, and they wanted to “keep it separate.” They are then attacked on the witness stand: how could this neck injury be such a big deal for you if you failed to mention it to your doctor at your general wellness checkup three months later?

Best advice I can give: no matter what your doctor is seeing you for, they are going to do a full “review of systems” at each visit where they survey your overall health- make sure to tell the doctor if you are struggling with and/or seeking treatment for a traumatic injury. They will usually note this, even if this is not what you are seeing them for. It's the truth, and it helps you avoid problematic medical records later.

About the Author

Scott A. Staples

Scott Staples came on board in 2006 as a clerk during law school, and joined the firm as an associate attorney in 2007. He was made a shareholder in the firm in 2010. Scott graduated, cum laude, from Washington State University Vancouver with a BA in English, and obtained his Juris Doctorate from Willamette University College of Law, with cum laude honors there as well. He has successfully represented clients in a variety of different types of injury cases, including auto collisions, premises liability, animal attacks, watercraft accidents, and construction site injuries. He has appeared, and won, before the Washington State Supreme Court (Weismann v. Safeco, 2012). Scott has volunteered time for the past several years at the Clark County Volunteer Lawyers Housing Justice Project. He has previously served on the new member and membership committees for the Washington State Association for Justice (WSAJ), and has acted as chair and co-chair of the WSAJ Clark County Roundtable. He is a member of the Washington and Oregon State Bar Associations, WSAJ and OTLA (state trial lawyer organizations), and is admitted to practice in all state and federal courts in Washington and Oregon. Scott was born and raised in Vancouver, attending Vancouver public schools and graduating from Hudson's Bay High School. He enjoys playing recreational basketball and softball, skiing, and spending time with his wife and three children.

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