How to Build a Strong Case After a Medical Injury: Key Documents and Evidence to Collect

Being injured by a doctor or other medical professional is one of the most traumatic experiences a person can have. You go to a doctor or hospital and expect that they will act professionally and make you feel better, not worse.

The unfortunate reality is that this isn’t always the case. In these situations, you may have legal recourse, depending on whether it was an unavoidable outcome or negligence on the part of the medical professional or hospital. Make sure you understand how to build a strong case after a medical injury, and the key documents and evidence to collect.

Steps to take right after a medical injury

In some medical malpractice cases, you’ll know right away that something went wrong. In other situations, though, it could be days, weeks, or even months before you realize that the doctor made a mistake. As soon as you realize that something has gone wrong, you should take the following steps:

Preserve evidence right away

When something goes wrong during a medical visit, it’s important to start preserving evidence as soon as possible. You’ll need as much proof as possible to prove that the hospital or medical staff should be responsible for your injuries. Always take photos of your injuries and how they progress if they’re visible, as this can provide an overview of your situation.

Start a pain journal

As soon as you realize you aren’t recovering as expected, you should start a pain journal, documenting what’s going on. Document things like:

• Levels of pain or physical issues
• Day-to-day limitations (can’t work, can’t cook, difficulty walking, or similar realities)
• Any days missed on the job, plus details about disrupted responsibilities
• Every doctor’s visit, tests, or urgent calls

The goal is to make sure you have a clear outline of how the doctor’s negligence affected your life and to make sure you don’t forget anything, since these cases can take a long time.

Request your full medical records

Your entire history at the hospital or clinic tells the story of what went wrong. Summaries aren’t enough—they’re incomplete and can be missing essential pages and information. Don’t depend on what you can print from a hospital patient portal login. Patient portals typically contain only part of your medical record and should not be relied on as complete.

You can request medical records yourself, but once you start working with a lawyer, they can also help you with this. If you do it on your own, ask specifically for your entire chart and all records. This may include some or all of the following:

• Admission sheets and entire discharge workups
• Doctor’s daily progress notes and physician orders
• A copy of the pharmacy dispensing logs and medication-administration records for your meds
• Every operation note, procedure result, and anesthesia log
• All lab work and radiology/scan write-ups, as well as the actual images on a disc
• Consults from outside physicians and any nursing or care plans on file

Ultimately, you want every single file and detail you can get your hands on so you can try to build your case.

Save all communications about your medical care

These days, so much of our communication is done through text messages and emails, and this is true for doctors and patients as well. Save all emails and MyChart messages so you have records of everything that was said to you. In addition to messages, you can look for and save a copy of any instructions you were sent home with. Take screenshots of these records and keep them somewhere safe.

Organize your evidence and build a timeline

Once you have evidence and have created an overview of what happened, it’s important to keep this evidence organized and build a more comprehensive timeline. Whether you do this online or by hand is up to you—just do it in a way that will be the most organized and make sense. This should include:

• What did you go to the doctor for?
• What happened during the visit or procedure?
• When did you realize something was wrong?
• What were your primary symptoms to start with, as well as any new or changing symptoms?
• Include dates and short descriptions of each doctor’s visit.

Make a note of anything that is going to help provide a full picture of what happened and why you’re owed compensation.

Speak to a medical malpractice lawyer

One of the—if not the—most important steps you can take after being injured by a healthcare professional is to speak with a medical malpractice lawyer. A lawyer is aware of necessary timelines relating to medical malpractice claims. They also know how to get evidence you may have missed or are having a hard time getting, and they can tell you what steps to take next to get your case started.

What to avoid after a medical injury

When you are hurt in an accident, everything can feel confusing. Insurance companies may start calling right away, and friends might continue to ask you how you’re doing. Mistakes in these early moments can affect the outcome of your case, so it’s important to know what to avoid:

Stay off social media

It is natural to want to tell friends and family about what happened after you’re injured—and this sometimes spills over into social media or text messages. However, insurers and defense lawyers often check online posts or could even subpoena text messages, hoping to use anything you say against you. Even an innocent update or photo can be used to cast doubt on the credibility of your claim and the severity of your injuries.

Don’t give a statement or provide records without talking to your lawyer

You may be asked to give a recorded statement about what happened or to provide full access to your medical records. While this might seem routine, you need to always remember that insurance companies are not on your side. Their primary goal is to save money, which means to pay you as little money as possible. Always speak to your lawyer before providing detailed information/access, or a recorded statement to an insurance company.

Resist quick, low settlement offers

Insurance companies sometimes make fast settlement offers. You might be tempted to take it because you’re dealing with time off from work and medical expenses piling up, but these offers are rarely going to account for the true extent of your damages. Taking a low offer too early can keep you from getting the help and compensation you actually need later on, and once you accept an offer, you can’t go back later and demand more. Always review every offer with your attorney.

Contact Nace Law Group to schedule a free consultation with a medical malpractice lawyer

If you’ve been injured by a medical professional, we understand how overwhelming this situation can be. Many people assume there’s nothing they can do if their visit or procedure doesn’t go as planned. Fortunately, this isn’t always the case. You can seek legal help to determine if you have a possible legal claim for medical malpractice, and we’re here to help. We have decades of experience and have recovered hundreds of millions of dollars for our clients. You don’t pay attorney fees unless we recover money for your injuries. Contact Nace Law Group today to schedule a free consultation with a medical malpractice lawyer. We have offices in Washington, D.C., West Virginia, and Maryland.