A 46-year-old woman was involved in a rear-end motor vehicle accident, resulting in injuries to her head, back, and neck. Our task was to review the medical records provided and assess the documentation correlating these injuries with the motor vehicle accident (MVA).
Process and Findings:
Initial Record Collection
We received 120 pages of medical records, which included diagnostic studies and office visits spanning several months. Our initial review found significant gaps, as the traffic collision report and the date of the collision were not available in the case notes.
Medical Records Review
Upon a thorough examination of the medical records, we noted documentation of neck pain and lower back pain. However, there was no explicit mention of the MVA, making it difficult to establish a direct correlation between the injuries and the accident.
Client Communication
We informed the client about the absence of explicit references to the MVA in the medical records and requested additional information, including the date of the incident. The client confirmed the date of the incident and acknowledged the lack of direct mentions of the MVA in the medical records, including MRIs and post-incident treatments.
Client Decision
After reviewing our findings, the client decided to cancel the request due to the identified weaknesses in the case documentation.
Case Focus Points:
- Medical Record Collection
Conclusion
By conducting a thorough and unbiased review of the medical records, we identified significant gaps in the documentation. This early identification helped the attorney make an informed decision, avoiding further pursuit of a weak case. Our detailed analysis and clear communication ensured that the client was fully aware of the status of the medical records and the implications for the case.
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