Medical Treatment and Documentation for Injury Claims

Medical documentation standards are governed by HHS regulations. The American Medical Association provides coding and documentation guidelines. Consistent treatment is critical per Nolo claims guidance.

How you handle medical treatment after an accident directly affects your injury claim. Insurance companies scrutinize your medical records for gaps, inconsistencies, and evidence to minimize your claim. Following best practices protects both your health and ythe legal rights.

Seek Immediate Medical Attention

See a doctor immediately after any accident, even if you feel fine. Many injuries—including whiplash, concussions, and internal bleeding—have delayed symptoms. Immediate medical evaluation creates documentation linking injuries to the accident and rules out serious conditions.

Follow All Medical Recommendations

• Attend all scheduled appointments
• Take prescribed medications as directed
• Complete recommended physical therapy
• Follow work restrictions and activity limitations
• Get recommended follow-up care and referrals
• Document any reasons you cannot follow recommendations

Avoid Gaps in Treatment

Insurance adjusters interpret treatment gaps as proof that injuries are not serious. If you stop treating for weeks or months then resume, they argue your later symptoms are unrelated to the accident. Maintain consistent treatment until your doctor releases you.

Be Honest and Thorough With Doctors

• Describe all symptoms, not just the worst ones
• Report when symptoms started and how they changed
• Disclose any pre-existing conditions (they will find them anyway)
• Explain how injuries affect daily activities
• Ask about prognosis and future treatment needs

Keep Your Own Records

• Pain journal documenting daily symptoms (1-10 scale)
• Photos of visible injuries throughout healing
• List of activities you can no longer do
• Record of all medical appointments
• All medical bills and receipts
• Mileage to and from appointments

Paying for Treatment

Do not skip treatment because you cannot afford it. Options include: health insurance (even if accident-related), medical payments coverage from auto insurance, letters of protection from yan attorney in our network to providers, and personal injury protection if available. Yan attorney in our network can help navigate payment.