Steps for a medical exam in a personal injury case.

If you are a plaintiff in a personal injury case in Eastern, Connecticut, you should understand your own medical records.  There are several important reasons for this.   The attorneys at The Bartinik Law Firm, P.C. have handled many personal injury cases, and have read pages and pages of records.  

The first step in understanding your medical records is to understand the basic format for medical records.  While not all records follow this format exactly, most will follow this logical progression.  

The Medical History.

The first step in a medical exam is the medical history.  Here, the doctor will ask you why you are here and what happened in the past that made you decide to come to the doctor.  For example, if you are treating for low back injuries after a car accident on Rt. 9 near Middletown, you should expect some reference to the "MVA" in the medical record.  When you explain your medical history, make sure explain that you are here due to your accident.  If you omit those facts the defense will try to claim that you have not proven that your medical care was caused from the accident.

The Physical Examination.

The next step in a medical exam is the physical exam itself.  This is when the doctor touches you, and records his or her observations.  As part of the examination the doctor might ask you how this or that feels.  For an exam involving a serious low back injury after a car accident you might see findings of "spasm" which are objective findings of muscle spasm.  

Diagnostic Testing.

In many injury cases diagnostic tests such as CT scans, and MRIs are used to help determine the nature of the injury.  These tests produce images that only trained doctors can interpret.  To evaluate a nerve injury, and EMG (electromyography) is used to measure the muscle's response to stimulations of the nerve.  


This is the protion of the medical exam where the doctor evaluates the history, exam, and tests and puts it all together to come to a conclusion.


The final part of the medical record is the plan.  Now that the doctor has assessed the situation, the doctor must now describe his or her plan to treat your condition.  This plan can include further treatment, a referral to a different doctor, medications, more testing, rest, a combination thereof. 

Where to get more information.

If you have been involved in a serious injury and need help then call The Bartinik Law Firm, P.C. at 888-717-4211.   We have offices convenient to you in Groton, CT, East Berlin CT, and Shelton, CT.  

Peter J. Bartinik, Jr.
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Civil Trial Attorney, Practicing Law in Connecticut