The Importance of Medical Records in South Carolina Personal Injury Claims

The moments after a car accident or a serious fall are chaotic. Your first thoughts are on your health, your family, and your vehicle. But as the adrenaline fades, a new set of concerns emerges: medical bills, missed work, and the confusing process of filing an insurance claim. This is when a personal injury claim becomes a necessity to recover damages. Understanding the role of your medical records is the first critical step in this process.

What Are Medical Records in a Personal Injury Claim?

When lawyers and insurance adjusters refer to “medical records,” they mean the complete and official file of your treatment, not just the final bill. This comprehensive documentation provides a detailed timeline of your injuries and your recovery path.

This file includes a wide range of documents, such as:

Ambulance and EMS transport notes
Emergency room admission and discharge papers
Notes from your primary care physician
Reports from specialists (like neurologists, orthopedic surgeons, etc.)
Diagnostic test results, including X-rays, MRIs, and CT scans
Surgical reports and anesthesiology notes
Physical therapy and rehabilitation progress notes
Chiropractic care records
Prescription records for medications
Notes from psychological or psychiatric counseling
All itemized bills from every provider

Why Are These Documents So Foundational to Your Case?

Your medical records are the primary evidence used to build your claim. They serve four essential purposes:

Establishing the Fact of an Injury: First, the records prove that you were, in fact, injured. A claim for a serious injury cannot proceed without medical documentation confirming a diagnosis.
Proving Causation: This is a vital legal element. Your records must connect your injuries directly to the at-fault party’s negligence (the accident). A doctor’s note stating that your back pain began “following a motor vehicle collision on [Date]” is a powerful piece of evidence.
Documenting the Full Extent of Your Injuries: The records detail the severity of your injuries, the pain you endured, the limitations you face, and the expected long-term prognosis.
Justifying the Value of Your Claim: Every dollar you request in a settlement must be justified. Medical records are the receipts and the justification for both your financial and non-financial losses.

How Do Medical Records Calculate Your Economic Damages?

Economic damages are the tangible, financial losses you have suffered. Your medical records are the main source for calculating these costs.

Past Medical Expenses: This is the most direct calculation. Your itemized bills from the hospital, specialists, therapists, and pharmacy are added up to show the exact cost of the care you have already received.
Future Medical Needs: If your injury is permanent or requires long-term care, your records are paramount. Your doctor’s prognosis, treatment plan, and notes about the need for future surgeries, ongoing therapy, or lifelong medication are used to project these future costs.
Lost Wages: Your medical records validate your time away from work. Doctor’s notes excusing you from work, disability slips, and records of physical limitations directly support your claim for lost income and diminished earning capacity.

How Do Medical Records Support Your Non-Economic Damages?

Non-economic damages—often called “pain and suffering”—are compensation for the non-financial, human impact of the injury. These are harder to quantify, which makes medical records even more important.

An adjuster will not simply take your word for your pain. They will look for objective proof in the records. This is where your physician’s notes, therapy records, and prescriptions become so significant.

Your records can help demonstrate:

Severity of Pain: Notes where the doctor records your subjective pain level (e.g., “patient reports 8/10 pain”).
Emotional Distress: Prescriptions for anxiety or depression medication following the accident, or referrals to a mental health professional.
Loss of Enjoyment of Life: A physical therapist’s notes detailing your inability to perform daily activities, or a doctor’s note restricting you from hobbies, sports, or family activities.
Permanence of Injury: A physician’s final report that assigns a permanent impairment rating or states that you will live with chronic pain or limitations.

The Insurance Adjuster’s View: How Do They Scrutinize Your Records?

It is essential to know that the at-fault party’s insurance adjuster reviews your medical records with a critical and skeptical eye. Their goal is to find reasons to minimize or deny your claim.

They are specifically trained to look for:

Gaps in Treatment: Unexplained weeks or months between doctors’ appointments, which they will argue means your injury was not serious or that you are already healed.
Delayed Treatment: Waiting days or weeks after the accident to see a doctor. The adjuster will argue that your injury must not have been caused by the accident.
Inconsistent Complaints: Telling the ER doctor your neck hurts, but not mentioning it again to your primary care physician.
Failure to Follow Medical Advice: Not filling a prescription, skipping therapy sessions, or not following a doctor’s orders.
Mention of Pre-Existing Conditions: Any note of prior injuries or degenerative conditions in the same area of your body.

What Is a “Pre-Existing Condition” and How Do Records Affect It?

This is a major source of anxiety for many clients. Many people have pre-existing conditions, like degenerative disc disease or old sports injuries. The insurance company will try to use this to claim they are not responsible for your pain.

However, South Carolina law is clear on this. The at-fault party is responsible for any aggravation of a pre-existing condition. You are not penalized for being more susceptible to injury than someone else.

Your medical records are the key to this fight.

Baseline Records: Your medical history before the accident establishes your baseline level of health.
Post-Accident Records: Your records after the accident show how the new trauma worsened or aggravated that old condition. A skilled attorney can use these records to differentiate the new injury from the old one, ensuring the at-fault party is held responsible for the harm they actually caused.

What Is a Medical Authorization (HIPAA Release) and Should You Sign It?

After an accident, the at-fault driver’s insurance adjuster will quickly send you a stack of forms. One of these will be a “Medical Authorization” or “HIPAA Release.” You should be extremely cautious about signing this.

The Health Insurance Portability and Accountability Act (HIPAA) protects your private medical information. This form gives the insurance company permission to request your records. However, the authorization they send is almost always intentionally broad. It often grants them permission to obtain your entire medical history, from every doctor you have ever seen.

They are not doing this for your benefit. They are digging for any past injury, illness, or unrelated condition they can use against you. You are not obligated to give them access to your entire life’s medical file. An experienced personal injury attorney will never allow you to sign a broad release. Instead, your attorney will provide the insurance company with only the records relevant to the injuries sustained in the accident.

What Specific Types of Medical Records Hold the Most Weight?

While all records are part of the story, some pieces of documentation carry more weight with insurers and juries.

Ambulance and EMT Reports: These are written at the scene or just after. They provide an immediate, unbiased snapshot of your physical state and your complaints right after the trauma.
Emergency Room Records: ER doctors are trained to quickly identify acute, traumatic injuries. Their initial diagnosis is a powerful piece of objective evidence.
Diagnostic Imaging (MRIs, CT Scans, X-rays): These are objective, visual proof of an injury. It is very difficult for an insurer to argue with a clear image of a herniated disc, a fractured bone, or internal bleeding.
Physician and Specialist Notes: These “SOAP notes” (Subjective, Objective, Assessment, Plan) tell the ongoing story of your recovery. They document your complaints, the doctor’s objective findings, the diagnosis, and the plan for your treatment.
Physical Therapy and Rehabilitation Notes: These records are highly detailed. They document your specific functional limitations, your pain levels during different activities, and your progress (or lack of progress) over time.

What Medical Record Mistakes Can Weaken Your Injury Claim?

Your actions during your recovery are documented in your records and can have a serious impact on your claim. To protect your case, avoid these common mistakes:

Delaying Medical Treatment: See a doctor immediately after the accident, even if you think your injuries are minor. Adrenaline can mask serious harm.
Missing Appointments: Keep all your scheduled appointments. Missing them signals to the insurer that your injuries are not a priority.
Not Following the Treatment Plan: If your doctor prescribes medication or therapy, follow through. If you do not, the adjuster will argue you are not trying to get better.
Minimizing Your Symptoms: Many people try to be “tough” and tell their doctor they are “fine.” This is recorded and will be used against you. Be completely honest about your pain and limitations at every visit.
Exaggerating Your Symptoms: Likewise, do not exaggerate. Doctors and therapists can often spot this (known as “malingering”), and if it is noted in your file, it can destroy your credibility.
Posting on Social Media: Insurance companies will compare your medical records to your social media. If your records state you have severe back pain, but you post a picture of yourself at a concert, you have seriously damaged your claim.

How Does an Attorney Use Your Medical Records to Build Your Case?

Managing medical documentation is one of the most important functions a personal injury lawyer performs. This is far more than just collecting bills.

A knowledgeable attorney and their legal team will:

Gather All Records: We will request and obtain the complete, certified records from every single provider who has treated you for your accident-related injuries.
Review and Organize: We meticulously review every page, organizing them into a clear timeline that tells the story of your injury and recovery.
Identify Strengths and Weaknesses: We analyze the records to find the strongest evidence and also to anticipate the insurance company’s arguments (like a gap in treatment) so we can prepare a counter-argument.
Consult Medical Professionals: In complex cases, we may retain a medical professional to review the records and provide an expert opinion that clarifies the severity and cause of your injuries.
Prepare a Demand Package: We assemble the most compelling records, along with a detailed legal argument, into a comprehensive demand package. This package is presented to the insurance company to negotiate a fair settlement, showing them we are prepared to prove every aspect of your claim.

Contact Peake & Fowler for Help with Your Personal Injury Claim

Your medical records are the most important evidence in your personal injury case. They should be handled with care, precision, and strategy. The team at Peake & Fowler is here to protect your rights and manage the complexities of your claim so you can focus on your health. We will handle the collection of your medical records, build a strong case based on that evidence, and fight for the full compensation you need to move forward.

To discuss your case, please call us at 803-788-4370 or complete our online contact form.

(803) 788-4370