Why your notes on the ‘mechanism of injury” matter


Why your notes on the ‘mechanism of injury” matter – I just finished running a case where the biggest single issue was the difference between the client’s version of the accident and the doctor’s records.

While as a doctor your role is to treat the injury—not to identify the mechanism by which the injury occurred— when it comes to your patient making a claim, the mechanism is crucial.

Using this recent case as an example, let’s discover why your notes can help, or hinder, your patient’s claim.

Same Injury, Differing Stories

Here are the notes from the case I was working on:

Doctor’s notes:
“Developed a backache since last Tuesday. No clear cause except working bent over. By Friday it was much worse. Complained of pain on straightening. Not a problem through night.”

Client’s explanation:
“Had some very mild back pain on the Tuesday. Wasn’t a problem after the first night. Was entirely better the next day. Was working bent over on the Friday when I got pulled violently to one side—by a ton of concrete unexpectedly coming out of the concreting chute—and it became much worse. Couldn’t straighten.”

A Doctor’s Role in a Patient’s Claim

While your patient’s claim may not be at the forefront of your priorities, your role as a doctor is to treat the patient, and not just the patient’s symptoms.

This responsibility does involve not putting your patient in a compromised position for a claim for a significant injury due to your having an inaccurate version of the patient’s poor summary of what happened. However, this does not mean that you’re responsible for investigating the injury or giving evidence about how it happened, because you didn’t see it.

It is your patient’s role to persuade the court that the injury happened the way they said it happened.

Ideally, your evidence should be restricted to expressing an expert opinion on whether the injuries you examined were consistent with the stated cause. This is the best way for you to support your patient’s claim.

How You Can Help Us to Help Your Patients

All too often, cases are seriously compromised because a taciturn, reserved, modestly educated person has provided a hopeless summary of what happened.

This is often the result of them believing that you only want to hear what their injury is, not how it happened. The issue is compounded if your notes contain inaccuracies or are worded in a way that’s ambiguous or don’t fairly summarise the events.

As a lawyer, my role is to take the time required to work out exactly how the injury occurred. But you only have 8 – 15 minutes with your patient to work out how the injury occurred, what it is, how to treat it, and how to document it. And knowing how long it takes for making a claim is essential as well.

So, in the limited timeframe you have, what can you do to help your patient now and in their future claim?

  • There’s no need to express your view about the stated mechanism of injury or whether you believe your patient is telling the truth.
  • If you do document the mechanism of injury, make sure it’s an accurate account. If not, don’t write down anything.
  • Alternatively, ask your patient to write the mechanism of injury down before they leave the surgery (around 60 words is a good length). Your staff can enter this explanation into your notes as the ‘stated cause of injury’.

Remember, if you’re unsure of the accuracy of your account, don’t include it in your notes. This is the best way to avoid going to court and is the simplest route to supporting your patient in their compensation claim.

Feel free to contact us so we can discuss your concerns anytime.