How to Explain Personal Injuries To Your Doctors and Lawyer

How to Explain Personal Injuries To Your Doctors and Lawyer

You are seriously injured because of another person’s negligence. How upset will you be when the defendant’s insurance company and lawyers, not only deny your legitimate injury claim, but use your own medical records against you? Unfortunately, this happens every day.

Insurance companies will carefully inspect your medical records, looking for anything that can be used against you. For this reason (and to make sure you get the medical care you need), personal injury victims need to be aware how to accurately and truthfully explain and document their injuries.

Doctors and therapists frequently do not ask enough questions, or the right questions to understand exactly what is wrong with you (see our web-post, “Is Your Doctor Listening to You?”). Just as often, patients fail to accurately explain their symptoms. As a result, injuries are missed, or not documented until months later.


What are the consequences? A doctor’s failure to understand your symptoms, may prevent you for getting the medical care you need and lead to a lesser injury diagnosis then you really have.  Also, a delay, or failure to accurately document these complaints, will make it harder for your lawyer to relate the injury to your accident. While you should be 100% honest about the severity of your injuries and symptoms, it is just as important to clearly explain all your injuries, not leave anything out, not minimize injuries, or let the doctor ignore an injury.


Let us share with you a few examples of problems you need to avoid:

  • An accident victim has back pain with a numbness going down her leg. On her information sheet, she only puts “back pain”; thinking that description includes the pain radiating from her back into the leg.  The doctor treats it as a soft tissue back injury and does not order any testing.  Although the leg pain is still there, the doctor never asks her and the patient still does not tell him (don’t wait to be asked!). Eventually the doctor orders an MRI anyway, which it shows a disc herniation. Problem solved? No. Because the insurance company will question the MRI findings based on her lack of leg (neurologic) complaints.


  • A man falls onto his hands and knees. He has minimal knee pain, but his wrist is swollen and very painful. Assuming his knee will get better on its own, the man only seeks treatment for the wrist. Over the next few weeks his knee gets much worse and after a long delay, asks the doctor to look at it. Problem solved? No. Because the insurance adjuster sees there were 15 medical and therapy visits over six weeks without any mention of knee pain. They deny paying for the knee injury, claiming he could have injured it sometime later.


  • On the very first visit, an accident victim correctly reports neck and shoulder pain. Although her shoulder hurts when lifting heavy objects, or lifting overhead, the doctor tells her the problem comes from her neck and ignores the shoulder as a source of injury.  After every therapy visit, the patient signs a daily treatment log, where the therapist only checks off neck pain; not shoulder. Because they are not doing anything for her shoulder, the patient eventually stops saying anything about it. The doctor gives her a disability rating only for the neck, with no mention of a possible shoulder injury. Eventually the client tells the lawyer about the shoulder pain and he arranges for her to see a different doctor. Testing shows a significant shoulder injury. Problem solved? Maybe. The insurance company will use the first doctor’s lack of finding and failure to note the patient’s complaints against her when trying to prove a significant shoulder injury. What should the patient have done?  For one, speak up! Ask your lawyer for help getting the doctor to document your complaints and test the shoulder, or insist on seeing a new doctor.


THE ROLL OF YOUR LAWYER IN MEDICAL CARE: We are not doctors, and cannot make medical decisions, but a good personal injury lawyer will play an important role in making sure clients get the medical care they need. It is our job to help clients fully, accurately and honestly documents their injuries. To do this a personal injury lawyer must be familiar with the client’s complaints and injuries, their past medical history and the medical treatment they are receiving. Clients do not always listen to us, or follow our advice; but if our advice is sound, we have done our job. Be open and honest with your lawyer. Please be sure to advise us of any potential problems with your case. This will allow us to deal with those problems in a manner that will help your case. Keep your lawyer informed. We can’t help you if we don’t know the problem.


This is a summary of medical advice we give clients early on.



Make a list if that helps you. Your doctor and therapists cannot help if they don’t know about all your complaints/injuries.

Do not minimize your pain/symptoms to your doctor. Don’t say it “bothers” you, if it “hurts” you. If you experience “pain” on activities or motions that did not hurt you before the accident, say it! This does not mean to exaggerate your pain. Always tell the truth.

Report all ongoing problems, even if not feeling it at the moment. Some injuries may only hurt you after a period of physical activity. Even if you do not feel that symptom at the moment of your visit, they must know about it.

Report all ongong problems, not just your main concern. At times, injuries that hurt the most early on gets better, and what you thought would get better, keeps getting worse.  – Don’t wait to be asked.

Pain That Radiates (travels) Into Your Arms, or Legs:  DO NOT just put “neck pain” if you sometimes have pain (numbness; weakness; pins & needles; etc.) that goes into your arms or legs, (see below, How to Explain Your Complaints). Even if the testing later shows you have a disc herniation, if all your complaints are just neck, or back, they will accuse the doctor of exaggerating your injury, or use it as proof the disc herniation reported on your MRI, does not really exist.

Shoulders, Elbows, Wrists, Knees, Ankles, or Feet:  If you have any of these problems, YOU MUST tell your doctors and therapists one EVERY visit.  EXAMPLE: If your shoulder is hurting, independent (separate) of your neck pain, make sure they know this on EVERY visit.


Don’t ignore the Pain Diagrams. If you have low back pain radiating (traveling) down your leg, DO NOT just circle the low back area.


Make sure ALL your complaints are documented in writing (on every visit). If you see the doctor/therapist only marking “neck pain” on the visit form, when you told them about arm, or wrist pain – SAY SOMETHING

What if the Doctor (or therapist) is Not Listening to You?  If your knee is the main problem and all they want to treat is your neck or back, speak up! If they are not listening to you, or for any other reason, you are not satisfied with your medical care, you need to consider finding a new doctor. TELL YOUR LAWYER.

Several years ago, our client was experiencing severe pain when moving her shoulder. The doctor kept telling her the problem was in her neck; which was only a little sore. We spoke to the physician and when nothing changed, we recommended she switch doctors. The new doctor ordered a shoulder MRI, which showed a serious injury. Not surprisingly the first doctor never mentioned shoulder pain in his reports. Fortunately, the client listened to us. Not only did she tell us about the doctor ignoring her shoulder pain, but on her first visit, she wrote on the new patient information form, “right shoulder pain”.  That helped establish the history of shoulder pain, even though the first doctor ignored it.


Don’t forget about the therapist. Treat the therapist just like your doctor. It is important to tell the therapist about all your ongoing complaints, on every visit.

Other accidents and injuries. It is very important that you tell the doctor AND LAWYER about any prior (earlier) accidents or injuries, including any injury claims before this one. If you don’t, you are only fooling yourself, since the insurance company will find out.




Your complaints will help the doctor understand what is wrong with you.

Example: If your back pain travels (radiates) into your legs, but you call it back pain”, the doctor may diagnose you with a soft tissue back sprain, when you really have a disc herniation.  The busy doctor may not figure it out on his own. He may not order the right tests, and an injury will be missed.

Example: We see clients call a “knee” injury, “leg pain”. When that happens, a busy doctor may think it is radiating pain form the back. BE CLEAR.

What is “Radiating” Pain or Numbness?   It is an uncomfortable and sometimes painful feeling that travels from one part of the body into another; such as from neck into your arm(s), or from your back into your leg(s). It can be a sharp pain; pins & needles; numbness and/or weakness. Some people describe it as a “shooting pain”.

Remember: If you have neck pain radiating into your left arm, do not just say you are having “neck pain”. This includes, when marking pain diagrams (do not just circle the back, if the back pain also radiates into your leg).

Tell the doctor and therapist about new or worsening injuries:  Be sure to tell them at each visit. Make sure they document it. – Don’t wait to be asked.


What If You are Not Having the Problem at the Time of Your Doctor Visit?


You will NOT experience all your symptoms all the time; including when you are at the   doctor’s office.

– You may only have the pain on certain activities, or

– It may get worse after work, or

– You may be avoiding doing the things that bring on the pain.

            – THAT DOES NOT MEAN THE INJURY WENT AWAY. Make it very clear!

Even if the doctor/therapist only asks about what you are feeling NOW, – Tell them about your ongoing problems, such as after doing your activities. YOU CAN SAY:

(a) “By the end of the work day, the pain starts shooting down my leg”; or

(b) “Whenever I have to climb stairs, my knee really hurts”.

Why We Hate, 1 to 10 Pain Scales. You will NOT have the same level of pain all the time.

Only telling them how you feel at the moment does not give them an accurate picture of what is wrong with you. It’s ok to make a big circle.  For example, draw a circle all the way around, 3, 4, 5, 6, 7.


Avoid using words that can be misunderstood: For example,

(a) If your pain is improving, but you are still having problems, do not just say it is “better.” The doctor may think it went away completely. Say, “it is not hurting as bad (or as often, etc.), but I am still having the problem”, or

(b) Do not say your neck is “sore”, or “bothers me”, if you have “pain”. If you have pain, say it.



Don’t forget about your Primary Care Physicians! Many clients don’t tell their PCP about accident related injuries because they are already seeing a specialist, or knows the PCP does not treat accident type injuries. Keeping your injuries from the PCP is a big mistake. If you are seeing a specialist, you do not need to see the PCP just to report your accident/injuries (unless you want his/her advice). However, when you go for a regular checkup, or for other reasons, you must tell the doctor. Try to make sure it is noted in his/her records.

Why is this important to your injury claim? As we explained, the insurance company’s doctors (hired guns) are paid to say there is nothing wrong with you; that your injuries are exaggerated; and/or that whatever you may have is not related to the accident. They will claim that your PCP records showing no complaints, is evidence you fully recovered or are not as hurt as you claim.


FINAL ADVICE: Your Lawyer Is There to Help You.  If you have any questions, please feel free to call us anytime.  305-661-3633.

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