What Medical Documentation Do You Need to Prove a Personal Injury Claim?

Legally reviewed by:
Rubin, Glickman, Steinberg & Gifford P.C.
March 29, 2023

After a serious car accident or any other personal injury accident, injured victims can recover monetary compensation to help cope with the financial strain of their injury by pursuing a personal injury claim. Personal injury claims hinge on the ability to prove the existence, cause, and severity of the victim’s injuries. Securing compensation for injuries often depends on medical documentation to make or break the case. 

With over 65 years of experience, the personal injury attorneys at Rubin, Glickman, Steinberg & Gifford, P.C. possess the skills, resources, and experience to give your case the focused attention it deserves. By combining the resources of a big firm and the personal attention of a small firm, we provide strong representation that helps our clients secure favorable outcomes. At the core of Rubin, Glickman, Steinberg & Gifford, P.C., our firm is passionate about protecting and preserving the rights and best interests of our clients. 

Medical Documentation: What You Need in a Personal Injury Claim

Medical records serve to establish a picture of the victim’s health. Following an accident, it is important to visit a medical professional as soon as possible so they can start building a paper trail of your injuries. Whether it is visiting the emergency room or your primary care physician, their initial assessment is important evidence. Proper documentation provides a solid foundation that proves the accident caused by the defendant directly led to your injuries.

Medical records are significant in establishing causation in a personal injury claim. Documents that are commonly presented include:

  • Doctor’s diagnosis
  • Medical imaging (X-rays, CT scans, etc.)
  • Line-item medical bills
  • Detailed doctor’s notes from patient visits 
  • Medical records from therapists, specialists or hospitals

These documents list not just the doctor’s diagnosis of the injury but also their plan to treat the injury and prove that the injury manifested as a result of the accident caused by the defendant’s negligence. 

Medical Bills: A Breakdown

Calculating a rough estimate of a personal injury claim requires compiling all resulting medical bills. Every service or therapy used in your treatment must be included in the calculations. Depending on your injury and treatment, bills should include:

  • Surgery costs
  • Blood work or scans
  • Ambulance fees
  • Doctor appointments
  • Prescriptions
  • Physical rehabilitation
  • Therapies
  • Diagnostic imaging

After a doctor’s or hospital visit or any other medical services necessary for your treatment, it is important to obtain a copy of an itemized medical bill. An itemized medical bill is a line-by-line breakdown allocating each service listed in the bill to a specific price. Itemized bills are the physical evidence of the expenses accumulating because of your injury. While medical bills prove the existence and causation of your injury, medical bills prove your need to be awarded damages. 

Photograph Noted Injuries

It is important to begin documenting your injury as soon as possible and continue documenting the health process throughout the various stages of your treatment. From broken bones to bruising, a photographic record of damages confirms the existence of the injury. It can play in your favor in a trial if it is necessary to go to court to secure a favorable verdict. Additionally, it is beneficial to keep track of your injuries and mental state in a journal. In this journal, jotting down the following is recommended:

  • How you are feeling
  • What physical symptoms you are experiencing 
  • The mental and emotional symptoms you are experiencing 
  • What doctor’s and other medical appointments have you attended 

Not all damages are qualifiable, like medical services that are billable. Non-economic damages aim to compensate victims for mental anguish and chronic pain. Keeping a well-written and photographed log of your injury can help when pursuing compensation for those hard-to-quantify damages. 

Contact a Talented and Skilled Personal Injury Attorney Today

At Rubin, Glickman, Steinberg & Gifford, P.C., we are committed to helping people harmed by someone else’s negligence obtain the fair treatment and compensation they deserve. Our dedicated attorneys understand the nuances of personal injury law and have successfully helped our clients secure favorable results for a wide range of personal injuries. 

When it comes to your health, livelihood, and financial well-being, it is important to have a strong attorney who can aggressively pursue maximum compensation on your behalf. Rubin, Glickman, Steinberg & Gifford, P.C. is here to help. Contact our firm today to schedule a consultation through our online contact form or call (215) 822-7575.

Legally reviewed by:
Rubin, Glickman, Steinberg & Gifford P.C.
Pennsylvania Attorney's
March 29, 2023
Established in 1952 by Irwin S. Rubin, Rubin, Glickman, Steinberg & Gifford P.C. boasts over 65 years of experience serving clients throughout Pennsylvania. Renowned for its commitment to ethical representation, the firm has garnered prestigious accolades, including being named the "Best Law Firm" for its outstanding legal defense work by U.S. News & World Report. Their team of seasoned attorneys, recognized as Pennsylvania Super Lawyers and Rising Stars, brings unparalleled expertise to a wide range of legal matters, ensuring exceptional representation for individuals, families, businesses, and organizations.