Quick Reference Guide
Medical Documentation Checklist
A comprehensive guide to organizing and tracking your medical information after an accident to strengthen your personal injury claim
Disclaimer: This checklist provides general information about organizing medical documentation after Oregon accidents, is not legal advice, and does not create an attorney-client relationship. Discuss your specific situation with a licensed Oregon attorney before relying on these recommendations.
Why Proper Medical Documentation Matters
Thorough medical documentation is the backbone of a successful personal injury claim. It provides objective evidence of your injuries, treatment, and recovery process. Well-organized medical records help:
- Establish a clear link between the accident and your injuries
- Document the severity and extent of your injuries
- Track your treatment progress and ongoing needs
- Calculate the full cost of your medical expenses
- Support claims for pain and suffering compensation
- Provide evidence of any permanent impairment or disability
Essential Documents to Gather
- Emergency Room Records
Admission records, doctor's notes, treatment records, discharge instructions, and any diagnostic test results from emergency room visits.
- Medical Provider Records
Office visit notes, treatment plans, and progress notes from all doctors, specialists, therapists, and other healthcare providers who treated your accident-related injuries.
- Diagnostic Test Results
X-rays, CT scans, MRIs, laboratory test results, and any other diagnostic testing related to your injuries, along with the radiologist's or specialist's interpretation of these tests.
- Medication Records
Prescriptions, medication lists, pharmacy records, and details about any side effects experienced from medications prescribed for your injuries.
- Therapy Records
Notes from physical therapy, occupational therapy, chiropractic treatment, and any other rehabilitative services, including initial evaluations, progress notes, and discharge summaries.
- Medical Bills and Expenses
Itemized bills from all providers, including hospitals, doctors, therapists, and any other medical professionals who provided treatment, as well as receipts for out-of-pocket expenses like medications, medical equipment, or transportation to appointments.
- Insurance Communications
Explanation of Benefits (EOB) statements, correspondence with insurance companies, and any pre-authorization or claim forms related to your medical treatment.
Creating Your Medical Documentation System
- Set up a dedicated filing system
Create a physical folder or digital filing system specifically for your accident-related medical records. Organize documents by provider, date, or document type, using whatever system makes the most sense to you.
- Create a treatment timeline
Maintain a chronological record of all medical appointments, treatments, and medication changes. Include the date, provider, purpose of the visit, and any significant findings or recommendations.
- Maintain a medical expense log
Track all medical expenses in a spreadsheet or dedicated notebook, including the date, provider, service provided, amount billed, amount paid by insurance, and your out-of-pocket costs.
- Keep a symptom and recovery journal
Document your symptoms, pain levels, limitations, and how your injuries affect daily activities. Make entries consistently (daily or weekly) to track changes in your condition over time.
Requesting and Reviewing Medical Records
- Know your rights to medical records
Under federal law (HIPAA), you have the right to access and obtain copies of your medical records. Providers must respond within 30 days, but they may take one additional 30-day extension if they send you written notice explaining the delay. Oregon law (ORS 192.563) generally requires release within seven working days, so follow up promptly if a provider misses these deadlines. Reasonable copy fees may apply.
- Submit formal written requests
When requesting medical records, use the provider's official medical records request form or submit a written request including your name, date of birth, contact information, specific records needed, and your signature. Keep copies of all record requests.
- Review records carefully
When you receive medical records, review them for accuracy. Check that they reflect the correct date of injury, mechanism of injury, symptoms reported, and treatments provided. Note any discrepancies for correction.
- Request corrections when necessary
If you find errors in your medical records, submit a written request for amendment to the healthcare provider. The provider must respond to your request within 60 days and either make the correction or explain why they declined.
Your Personal Injury Symptom Journal
A detailed symptom journal can significantly strengthen your personal injury claim by documenting the daily impact of your injuries. Consider including these elements in your journal:
- Daily pain levels
Rate your pain on a scale of 0-10 for different body areas, noting any changes or patterns.
- Detailed symptom descriptions
Document specific symptoms (pain, numbness, dizziness, etc.), their location, duration, and what triggers or alleviates them.
- Medication usage
Record when you take medications, dosages, effectiveness, and any side effects experienced.
- Activity limitations
Note activities you cannot perform or must modify due to your injuries (work tasks, household chores, hobbies, etc.).
- Emotional impact
Document psychological effects such as anxiety, depression, frustration, sleep disturbances, or other emotional challenges related to your injuries.
- Social and family impact
Record how your injuries affect your relationships, social activities, and family responsibilities.
Important Legal Disclaimer
This information is for educational purposes only and does not constitute medical or legal advice.
- Johnson Law, P.C. does not endorse specific healthcare providers or medical facilities
- Always consult with qualified medical professionals for medical advice and treatment decisions
- This guide does not create an attorney-client relationship
- For legal advice specific to your situation, please contact our office for a consultation
Educational Resources
Understanding Your Medical Care Options
Learn about the types of medical care you may need after an accident and what to look for when choosing providers
Physical Therapy After Accidents
Learn what to look for in a physical therapist, including experience with accident injuries, insurance acceptance, and documentation practices.
Diagnostic Imaging Guide
Understand the different types of diagnostic tests (X-rays, MRIs, CT scans) and what questions to ask imaging centers.
Pain Management Options
Understand when pain management treatment may be necessary and what qualifications to look for in specialists.
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