Medical Records and Credibility in an Injury Claim

Medical records and credibility decide more general damages assessments than any legal argument does. A judge who accepts the plaintiff’s account of the injury will award within the range the medical evidence supports. A judge who does not will award well below it, on the same injury.

The Clinical Note Is the Contemporaneous Record

What a doctor wrote at the time matters because it was written before the claim mattered to anyone. A note recording that the pain was improving three weeks after the accident is hard to displace at trial with a memory of constant pain. Family doctor charts, physiotherapy records, walk in clinic entries and hospital records are all produced.

How Medical Records and Credibility Interact

Consistency is the test. The plaintiff’s evidence, the clinical record and any specialist report should tell one story. Where they diverge the court usually prefers the record, and every divergence is put to the plaintiff in cross examination. A small inconsistency is survivable. A pattern of them is not.

Gaps in Treatment Are Argued Against You

A long period without treatment is read as a period without symptoms, whether or not that is true. Where a plaintiff stopped attending because the treatment was not helping, or because coverage ran out, that reason should be recorded at the time rather than explained years later. The minor injury caps chapter explains why continuity of documented impairment matters even more where a cap is in issue.

Prior Records and the Defence Medical Examination

The defence is entitled to relevant pre-accident records, which is how the argument in the pre-existing conditions chapter gets built. The defence can also require an examination by a doctor of its own choosing. Both are normal features of a contested claim. Neither means something has gone wrong. The rules governing production and examinations sit in each province’s rules of court, and the Nova Scotia rules are published by the Nova Scotia courts.

What to Do About It

Report every symptom to the treating doctor, including the ones that seem minor, because a symptom the record never mentions is a symptom the defence will say did not exist. The firm reviews the full record before advancing a valuation on car accident and long term disability files, and the assessment method is in how courts assess general damages.