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10 Documents To Support Your Medical Malpractice Claim

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November 14, 2023

If you are considering a medical malpractice claim, it is important to understand what types of documents and other records you should keep. These documents will be used as evidence to support your legal claim for compensation. When crucial evidence is missing or incomplete, it can affect whether or not your medical negligence claim is successful, or how much compensation you are awarded. Fortunately, even if you do not have some of the documents listed here, your attorney may be able to obtain copies for you. If you have questions about documents, evidence, or anything else related to a medical malpractice claim, contact the medical malpractice attorneys at Morris James online or by calling 302.888.6857 today.

Here we discuss ten of the most important documents you should keep to ensure the success of your medical malpractice claim.

1. Medical Records

Medical records are the most important evidence in a medical malpractice case. They contain detailed information about your treatment, including any diagnoses, procedures, medications prescribed, and notes from your healthcare providers. It is essential to collect all medical records from every healthcare provider involved in your treatment at issue, including records from hospitals, clinics, and specialists.

Your medical records should include medical test results such as blood work, X-rays, and MRIs. These can provide important information about your condition before and after the medical malpractice event. They can also contain evidence of errors made by your healthcare provider in the interpretation of the test results.

Informed consent forms included in your medical records indicate that you gave permission for a certain procedure or treatment. These forms can be used to show that the healthcare provider failed to disclose the risks and potential complications associated with the procedure or treatment. This can be a crucial piece of evidence in proving negligence on the part of the healthcare provider.

Prescription records can also provide insight into your treatment and any potential errors made by your healthcare provider, pharmacist, or the equipment administering the medication. These records should include all prescribed medications, dosages, time and manner of administration, and any adverse reactions you experienced.

2. Medical Bills and Other Receipts

Medical bills and other receipts serve as evidence of the financial impact of the alleged malpractice. These documents should detail all expenses incurred during and after your treatment, including charges for hospital stays, doctor's visits, surgeries, medications, therapy or rehabilitation sessions, and any medical equipment needed for recovery. These records can also include transportation expenses for medical appointments and any out-of-pocket costs you have paid. 

You may have expenses that are not medical that can also be included in your claim, such as the cost of home renovations or vehicle modifications that are necessary as a result of your injuries. The cost of at-home nursing care or similar services may also be eligible for compensation.

3. Insurance Documents

Insurance documents play a vital role in substantiating your medical malpractice claim. They consist of your health insurance policy, Explanation of Benefits (EOBs), and any correspondence with your insurance company. Your policy details the terms and conditions of your coverage, while the EOB provides an itemized account of the medical services you received, the charges that you incurred, and the amounts that were billed to your insurance. Any correspondence with your insurance company is also important.

4. Correspondence with the Healthcare Provider or Insurer

All written communication between you and your healthcare provider or insurance company can serve as significant evidence in your medical malpractice claim. This might include emails, letters, or notes of telephone conversations, or communications regarding your treatment, any complaints you may have lodged, or discussions about your condition. Similarly, any communication with the insurance company regarding claims, disputes, or denials should be preserved. This evidence can illustrate your efforts to address the issue and any negligence or misconduct on the part of the healthcare provider or insurer. Sharing these documents with your medical malpractice lawyer can provide further context to your claim and help build a stronger case for compensation.

5. Witness Statements

If there were witnesses present during the course of your treatment or procedure, their statements can be valuable evidence in a medical malpractice claim. Witnesses can also provide evidence of the impact of the malpractice on your daily activities and quality of life. Your attorney will help you to identify witnesses and gather their statements when necessary during the course of your medical malpractice claim.

6. Treating Expert Opinions

In some cases, medical doctors who have treated or are treating you may express expert opinions about your care, treatment, or prognosis. These treating physician opinions are used to support your medical malpractice claim by providing a professional, and often unbiased-by-litigation, analysis of some aspect of your case.

7. Employment Records or Tax Returns

Employment records and tax returns are evidence of your lost wages and benefits. In a medical malpractice case, victims often face substantial economic losses due to the inability to work or a reduction in their working capacity. These losses are referred to as lost wages and benefits, and they can form a significant part of your compensation. Similarly, your future loss of earnings may also be compensable. This accounts for the reduction in your ability to earn in the future as a result of the injury. It is calculated based on a variety of factors, such as your age, work-life expectancy, skills, and the severity of your injuries. These calculations often require the expertise of economic loss experts to accurately predict future earning potential and loss.

8. Personal Journal or Diary Entries

If you kept a personal journal or diary during your treatment, these entries can be used to document your medical appointments, periods of treatment, any changes in your condition, symptoms, or concerns you may have raised with your healthcare provider. This can be valuable evidence in showing the progression of your condition and any potential negligence on the part of the healthcare provider.

A journal is also useful for documenting your pain and suffering, including physical discomfort and emotional anxiety. Pain and suffering is often a substantial part of the compensation awarded in a medical malpractice case. A journal can be used to record your daily pain levels, mobility issues, sleepless nights, feelings of depression, anxiety, fear, or frustration, and the impact of these problems on your quality of life. Do remember that this journal could become a public document if it is used as evidence in your case.

9. Photographs, Videos, and Text Messages

Photographs, videos, and text messages serve as powerful tools to document your condition, your injuries, and your recovery process. They capture a real-time narrative that words often cannot express, holding undeniable evidentiary value. For instance, photographs of physical injuries, surgical wounds, or any visible adverse reactions to a treatment can substantiate your claim. Similarly, videos can illustrate mobility issues, symptom severity, or other physical hardships caused by your healthcare provider’s negligence. And text messages can document complaints and clinical responses by medical professionals that are not captured by medical records. Photos, videos, and text messages should be dated and/or timestamped, which most devices now do automatically.

10. Death Certificate and Autopsy Report

In tragic cases where medical malpractice results in a patient's death, the death certificate and autopsy report become crucial pieces of evidence. The death certificate provides the cause and manner of death, which can substantiate claims of medical negligence. The autopsy report, on the other hand, gives more detailed information about the deceased's exact cause of death and may reveal evidence of malpractice that was not apparent before. These documents can provide compelling proof of a causal connection between a healthcare provider’s malpractice and the fatal injuries to the patient.

When your attorney can present strong evidence to support your medical malpractice claim, you are more likely to receive full and fair compensation, even if your case is settled before you get to trial. You can help your chances of success if you are diligent about keeping copies of the documents listed here.

At Morris James, our attorneys have been standing up for victims since we opened our doors in 1932. If you have been a victim of medical malpractice, our medical malpractice attorneys can help. More information is available in our Medical Malpractice FAQs, or you can contact us online or at 302.888.6857 to talk to one of our experienced team about your case.

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