Differences in records often need context
Differences in records can arise because documents were created at different times, for different purposes or from different sources. A short emergency note and a detailed later history may not use the same words. Before treating that difference as a contradiction, we need to understand what each record was intended to capture.
Careful preparation gives important facts their proper context and helps your experience be understood fairly. I would rather identify a question early and investigate it than leave a client wondering why an ordinary detail became important at trial.
That does not mean every discrepancy can be explained away. It means each should be evaluated honestly, with attention to its source and significance. A reliable explanation is more useful than either ignoring the issue or overstating its importance.
Identify what the record actually says
A summary may sound different from the underlying document. Read the full entry and the surrounding material. A note that a person was improving may address one symptom rather than every limitation. A date may refer to the visit rather than the event being described.
We should also identify who supplied the information. A provider may record the patient's history, a family member's account or information copied from another record. Those sources can have different levels of detail and personal knowledge.
If the meaning remains uncertain, additional records or testimony may help. The answer should come from a reliable source, not from a lawyer inventing an interpretation that the document cannot support.
Medical records reflect stages of recovery
An initial visit may focus on immediate concerns. A later appointment may investigate a problem that became more apparent when the person returned to normal activities. That sequence can explain why the records become more detailed over time.
The timing should be described accurately. If you first noticed a limitation after attempting a work task, say that. Do not assume the case requires you to state that every later problem was fully apparent at the scene.
Your providers can evaluate the medical significance of the history. The lawyer's task includes assembling the records and ensuring that an appropriate expert has the information needed to explain the connection, rather than treating every change in wording as a medical conclusion.
Memory and documents should be compared fairly
People do not ordinarily remember every appointment date or the exact length of every interruption in their routine. A calendar or record may help identify those details. It is appropriate to distinguish a refreshed recollection from something you remembered independently.
If you are uncertain, say so. An estimate should remain an estimate. The effort to make every detail sound exact can create an inaccurate account where a straightforward explanation would have been sufficient.
Preparation can identify which facts require confirmation and which are not material to the dispute. That helps a client focus on answering the question asked without feeling responsible for reconstructing an entire history from memory.
Genuine errors can be addressed transparently
If a medical record contains incorrect or incomplete information, ask the provider about the amendment process. Federal health privacy guidance recognizes a process for requesting amendments and, in appropriate circumstances, submitting a statement of disagreement.
A correction should be identifiable as a correction. Do not alter the original document or present a later explanation as though it was recorded at the earlier visit. Preserve both the original and the response to the request.
Other records may have different correction procedures. Tell your lawyer about the issue so that the appropriate process can be considered. A factual mistake should be addressed with supporting information, not merely a request to remove an unfavorable sentence.
Prior history can help explain what changed
An earlier injury or condition may be relevant to the medical comparison. Records showing how you functioned before the incident can help distinguish a new injury from a preexisting problem or identify an aggravation.
That history should be discussed openly with counsel. It does not automatically defeat a claim. It allows the case to be evaluated on the actual baseline and gives medical experts a more complete foundation for their opinions.
If an old record uses a term you do not understand, ask about it. A diagnosis in a chart should be interpreted by someone qualified to do so, with attention to the circumstances in which it was recorded.
Trial preparation should clarify, not script
Your lawyer can review documents and explain the subjects likely to be discussed. The purpose is to help you understand the process and identify matters that need clarification. It should not turn your testimony into memorized phrases.
Answer from your own knowledge. If a question contains an assumption you do not agree with, explain that rather than accepting the premise simply to give a short answer. If you do not understand the question, ask that it be clarified.
An advocate can place a disputed entry in context through the appropriate evidence. That may involve the author of the record, another document or an expert explanation. The approach should fit the particular issue.
Raise concerns early
If you notice differences in records, tell your lawyer before a deposition or hearing when possible. Early notice provides time to obtain missing information and evaluate the significance.
An injury case should present a fair account of what happened and how it affected you. Careful attention to the records helps ensure that an isolated phrase does not replace the fuller explanation the evidence supports.
Sources and Further Reading
About Michael B. Fusco
Michael B. Fusco is a New Jersey personal injury attorney certified by the Supreme Court of New Jersey as a Civil Trial Attorney. Read Mike’s biography and credentials.
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General Information
This article provides general information, not legal advice for a particular situation. Laws and policy terms must be applied to the actual facts. Reading this article or contacting the firm does not, by itself, create an attorney-client relationship.