How to Review Medical Records for Personal Injury Claims – Quick Tips

When building a strong personal injury case, medical records are the backbone of the evidence. They prove that injuries exist, connect them to the accident, and support the monetary value of the claim. Whether you’re a personal injury paralegal, claims adjuster, attorney, or litigation support specialist, knowing how to review medical records efficiently is critical to successful legal case preparation.

This guide offers quick, practical tips for conducting a personal injury medical record review like a professional—organized, accurate, and litigation-ready.

Medical Record Review for Personal Injury Claims

1. Understand Why Medical Records Matter

Medical records help establish:

• Causation – Were the injuries caused by the accident?

• Severity of injuries – How serious and life-altering are they?

• Medical necessity – Are treatments related and reasonable?

• Damages – What are the economic and non-economic losses?

• Future medical needs – Is there long-term impairment, disability, or continued care?

Injury claims revolve around the evidence in medical documentation, not just client complaints or accident narratives. Solid PI litigation support starts with strong medical proof.

2. Gather Complete and Certified Medical Records

A complete medical record package should include:

• EMS/ambulance report
• Emergency room records
• Initial evaluations
• Imaging & diagnostics (X-ray, MRI, CT, EMG)
• Physical therapy & chiropractic notes
• Pain management records
• Orthopedic or specialist reports
• Surgical and procedure notes
• Pharmacy/medication logs
• Work status or disability slips
• Medical bills (itemized)
• Health insurance lien details
• Prior treatment records, if relevant

Tip: Maintain a medical record index to track which records are received and which are still pending. Many attorneys assign this task to personal injury paralegals or outsource it to medical chronology services to ensure accuracy and save time.

3. Organize by Provider and Date

Chronological review is essential. Organize records:

• By date of service (DOS)
• By provider or facility
• With page numbering for easy citations
• In treatment phases – ER → Primary care → Diagnostics → Therapy → Specialists → Pain management

A structured format makes your review clear and courtroom-friendly. It also lays the foundation for a later medical chronology summary.

4. Build an Accurate Timeline of Treatment

A consistent treatment timeline makes or breaks a personal injury claim. Look for:

Timeline Component	Example Notes
Date of Accident	02/15/2025
First Treatment	02/16/2025 – ER Visit
Diagnostics	MRI on 03/02/2025
Consistent Care	PT 2–3x/week
Gaps in Treatment	6-week delay – needs explanation
Aggravation or Relief	Pain improved/worsened at key dates
Maximum Medical Improvement (MMI)	Declared by the provider

Why it matters: Gaps in treatment, delayed onset of care, and inconsistent complaints weaken claims. Insurance adjusters use these against injured clients. A strong personal injury medical record review highlights issues early so they can be addressed.

5. Focus on Key Sections of Each Record

Every medical record contains important information, but here’s where to focus your review:

Section	What to Look For
Chief Complaint	Type, location, and severity of pain
History of Present Illness (HPI)	Connection to the accident
Past Medical History	Prior injuries or conditions
Physical Examination	Restricted ROM, tenderness
Assessment/Diagnosis	ICD-10 injury codes
Treatment Plan	PT, MRI, referrals
Disability/Work Status	Light duty, no work
Prognosis	Temporary or permanent
Causation Statements	“Injuries consistent with an accident”

Highlight anything that supports your case or may be a defense weakness.

6. Identify Defense Red Flags in the Records

Look for indicators that insurance companies or defense attorneys may exploit:

• Pre-existing injuries
• Prior claims or accidents
• Degenerative findings in imaging
• Low pain scores
• Missed appointments
• Symptom exaggeration notes
• Doctor notes like “patient not compliant”
• Gaps in treatment
• Delayed treatment after the crash
• Accident described differently to a provider

Don’t panic—these issues can often be explained. But first, they must be recognized and documented as part of legal case preparation.

7. Link Medical Evidence to Legal Elements

A strong medical review must connect the dots between medicine and law. Here’s how:

Legal Element	Supported By
Causation	Doctor notes, mechanism of injury
Damages	Billing records, pain scores
Functional Loss	PT notes, work restrictions
Permanency	Orthopedic evaluations
Pain & Suffering	Consistent symptom reporting
Future Costs	Life care plans, prognosis notes

Use phrases like:

• “Within reasonable medical probability…”
• “Injury was caused by the motor vehicle accident…”
• “Patient should continue long-term treatment…”

8. Verify Billing and ICD-10/CPT Codes

Medical bill auditing supports settlement demands. Check:

• ICD-10 diagnosis codes (confirm relevance to injury)

• CPT billing codes (verify procedures)

• Treatment frequency and duration

• Reasonableness of charges

• Duplicate billing or unrelated charges

Example:

• ICD-10 Code S33.5XXA – Sprain of lumbar region

• CPT 97110 – Therapeutic exercises

This strengthens the demand package by showing medical necessity and economic damages.

9. Create a Clear Medical Summary or Chronology

Every personal injury case benefits from a medical chronology summary. It converts hundreds of pages of records into a clear narrative.

Here’s a simple structure:

• Injury Summary
• Treatment Timeline
• Pain Progression
• Diagnostic Testing Results
• Referrals and Specialist Notes
• Surgery or Injections (if any)
• Prognosis and Future Care
• Medical Specials Summary
• Missing Records Report

This is where medical chronology services and PI litigation support teams save massive attorney time and help prepare demand letters, mediation briefs, or trial exhibits.

10. Tools That Make Review Easier

To streamline review:

Tool	Use
Excel/Sheets	Treatment logs
Case Management Software	Clio, Filevine, MyCase
Medical Reference Tools	ICD-10 lookup, WebMD
Redaction Tools	Adobe, SmallPDF
Outsourced Services	Medical Chronology & Summaries

11. Common Mistakes to Avoid

• Skipping prior medical history
• Ignoring causation language
• Failing to summarize findings
• Missing follow-up or future care notes
• Forgetting to check billing consistency
• Not tracking missing records
• Overlooking medication lists and pain scores

Final Thoughts

A personal injury medical record review must be accurate, complete, and persuasive to maximize a case’s value. It helps establish liability, document damages, and enhance negotiation power before settlement or trial. That’s why many attorneys rely on personal injury paralegals or outsource to trusted medical chronology services for faster turnaround and litigation-ready summaries.

If your law firm needs medical record review, medical chronologies, treatment summaries, billing summaries, or demand letter medical sections, our team can help. We at Eternity Paralegal Services provide accurate, attorney-ready PI litigation support with fast turnaround and affordable rates.

Get litigation-ready medical summaries today! Contact us to request a sample or free trial support.