Your Medical Records

Being a good patient can be challenging under any circumstances.  The challenges can be particularly unique when a mild traumatic brain injury is involved.  There are certainly compelling medical issues at play, for certain, but also matters that can have a serious impact on any lawsuit that might be brought.  Awareness of these medical/legal issues, and knowing how to handle them, can sometimes make the difference in winning and losing.  That difference is often lurking in the content of your doctor’s medical records.  How accurate are they?  Are they comprehensive?  Do your medical records reflect just how difficult your struggle has been?  If not dealt with properly, the medical records of your treating physician(s) can create real problems in both your medical treatment and in the financial recovery you’re seeking.

Things You Can Do

First, you need to find the right doctor.  Your MTBI needs to be diagnosed as soon as possible so that treatment can start.  Family physicians are great for lots of things, but are notoriously poor at diagnosing, much less treating, this type of injury.  All too often MTBIs are misdiagnosed leading to improper or inadequate treatment, and inaccurate and distorted medical records.  The medical records of your treating physicians are vitally important evidence in your case.  They need to correctly reflect a diagnosis of brain injury and what caused it.  You need to see a qualified physician, for example, a neurologist, early on.  Not all neurologists work with brain injury patients.  You will need to find one who does.  Fortunately, we know and work with some of the best physicians, clinicians, and therapists in Texas for the treatment of MTBI.

Second, you need to make a list of your symptoms.  Once you find the right treating physician, it’s important for that doctor to know, and your medical records to reflect, a detailed listing of all your MTBI symptoms over time.  MTBI symptoms very widely and will change during your recovery.  Because of the nature of this injury, it may be difficult when you visit your doctor to know and remember each problem you’re having. 

We strongly encourage our clients to make a list of their symptoms before arriving at the doctor’s office, and then simply hand that list, with a date on it, to the doctor so he/she will know your problems in detail, and so that the list can then become a part of your permanent records. We also suggest you ask a friend or family member to help with the list.  They may recall things you’ve forgotten or may simply be unaware of.  And whenever possible, MTBI patients should take a family member or friend with them when they see their doctor and have them in the room during examination.  This can help you stay on track with symptom discussion and can also help you recall later what was discussed. Third, be sure and disclose all prior medical conditions and treatments.   Should you bring a lawsuit for your MTBI, the defense lawyer representing the at-fault party will get all your past medical records.  He/she is entitled to them with some limitations.  They are looking for prior head injuries of any kind, however slight, and other injuries and conditions that could arguably relate to lawsuit claims.  It’s very important you tell your treating doctor about prior head injuries of any kind, not matter how slight, so later, when the defense lawyer gets your doctor’s records, the prior head injuries are clearly stated.  In this way you don’t look like you’re trying to hide something. To learn more about how to better manage your doctor relationships while receiving treatment for your MTBI, see the featured article by Charlie Waters in The Center database: Litigating Mild Traumatic Brain Injury Cases:  What a Family Needs to Know.


Brain Anatomy
Traumatic Brain Injury Overview
Texas Laws to Know
Brain Injury Litigation: Simplifying the Complexity
Featured Articles by Charlie Waters
Traumatic Brain Injury Resources