No investigation of a serious compensation case can be considered complete without a careful review of the hospital record, if one exists. The investigator will find that most hospital records are generally uniform in form. They will usually contain: discharge diagnosis, admission sheets, history sheets, preliminary diagnosis and impressions, examination records, progress notes, consultation reports, X-ray reports, operating room records, pathologist’s reports, laboratory tests and results, temperature charts, order sheets, nurses notes. Working with a local attorney would be good for your case.
Hospital records are usually particularly significant because they most often present an impartial, non-partisan account of the history of an accident, the onset of symptoms, the injuries sustained, and the past medical history of the claimant. Many times a hospital record can support a claim being made or can show that it should be rejected. Experience has demonstrated that claimants are most prone to tell the whole truth upon being admitted to the hospital, particularly if the admission was immediately following an accident, or attack of illness on the job, or at home.
This knowledge will also be invaluable to the investigator whenever he finds it necessary to interview a doctor. It will give him the necessary confidence to sit with a doctor in his office and intelligently discuss a case. The doctor will readily recognize an investigator’s perception and, as a result, will be prone to cooperate and speak frankly.
The purpose of interviewing a doctor is usually to get answers to these elements of any claim – “what,” “when,” “where,” “how,” and “why.” The doctor can disclose; when he began to treat the claimant; what history he received when the claimant was first seen; what his medical findings were on the first examination; if X-rays were taken, what they revealed; the diagnosis; the treatment rendered; the degree of disability and when and if it changed its status, for example, from total disability to partial disability; when disability ended; and, the past medical history of the patient.
Report May Be Filed
The doctor may have already filed reports answering some of these questions. If so, the investigator’s job may be to get information on questions not dealt with by the doctor in his reports.
Where the doctor has failed to file any medical reports such failure should lead to the suspicion in the mind of the investigator, that the doctor never received a history of the accident from his patient or at least to the presumption that the accident did not arise out of or in the course of the patient’s employment. This is true because the Workmen’s Compensation Laws in most of the states usually make it obligatory for a treating doctor, or a consultant, to file reports with official bodies within certain limits and on prescribed forms. Working with personal injury is not an easy task. But it would be better to have a lawyer on your side to work things out for you.