Medical Records That Document Your Injuries and Treatment
Medical documentation can connect your injuries to the accident and show how they have affected you over time. Each provider’s records capture a different part of that story, which is why it is worth saving documents from every stage of your care. Getting prompt medical attention after an accident also creates an early record of symptoms and can establish a connection to the accident.
Emergency Room and Hospital Records
Emergency room and hospital records document your condition close to the time of the accident. Test results, diagnoses, procedures, and discharge instructions can show what providers observed and whether you needed immediate or follow-up care.
Specialist Records
A specialist’s records usually provide more detail about a particular injury than an initial examination does. Keep visit summaries, diagnostic results, referrals, and treatment recommendations from every specialist you see.
Physical Therapy and Rehabilitation Records
Rehabilitation records show how your recovery progresses between major medical appointments. Therapy notes may document symptoms, physical limitations, setbacks, and improvements that likely won’t appear in a hospital record.
Prescription and Medication Records
Prescription records show which medications your providers have ordered, when you filled them, and how long your treatment has continued. Keep medication lists and pharmacy records as part of your medical documentation.
Medical Bills and Other Accident-Related Expenses
Medical records show the care you received, but bills, invoices, and receipts document what that care cost. Keep records of any amount you paid out of your own pocket, even if insurance covered part of the expense.
Hospital Bills
Keep bills from emergency rooms, hospitals, and other medical facilities, even if your insurance company paid part of the cost. Itemized statements and explanations of benefits can show the amount charged, the amount covered by insurance, and the remaining balance.
Prescription and Medical Equipment Costs
Save receipts for prescription medications and medical equipment, including braces, crutches, or mobility aids. If you rent or replace equipment during your recovery, keep those invoices as well.
Travel Expenses
Trips to medical appointments can come with costs that are easy to overlook. Keep a mileage log along with receipts for parking, tolls, public transportation, or rideshare services used to reach appointments.
Rehabilitation and Ongoing Care Costs
Save invoices from physical therapy, rehabilitation programs, and in-home care related to your injuries. If a provider recommends future treatment or long-term support, keep the written recommendation and any available cost estimate, even if you have not yet received the care.
Documents Showing Lost Income and Financial Losses
Employment and financial records put actual numbers behind the income you lost because of an injury. That loss is not limited to a regular paycheck. Self-employed individuals and business owners may need a broader paper trail, including tax returns, invoices, contracts, profit-and-loss statements, and records of work they had to cancel.
Wage Statements
Keep pay stubs, W-2 forms, tax returns, and other records showing what you earned before and after the accident. These documents can establish missed pay, reduced hours, and changes to your usual earnings.
Employer Letters
An employer letter can confirm your position, rate of pay, normal schedule, and the dates you missed work. It may also document reduced duties, fewer hours, or paid leave you had to use during your recovery.
Evidence of Reduced Earning Capacity
Reduced earning capacity concerns the injury’s long-term effect on your ability to work, not just the paychecks you have already missed. Medical work restrictions, employment history, and vocational evaluations may show that you can no longer perform the same job, work the same hours, or pursue the same opportunities.
Accident Reports and Evidence From the Scene
Evidence from the scene may preserve details that are difficult to reconstruct later. Reports, photographs, and statements from witnesses who saw the accident can clarify where it happened, what conditions were present, and how events unfolded. Some of this evidence can disappear quickly, so gather or request copies as soon as you reasonably can.
Police or Accident Reports
A police or accident report may contain insurance information, witness details, a diagram of the scene, and the responding officer’s observations, so keep the report number and request a complete copy. Under New York’s car accident reporting laws, drivers must file a Report of Motor Vehicle Crash, Form MV-104, with the DMV within 10 days if someone was injured or killed or the collision caused more than $1,000 in damage to one person’s property. When someone is injured or killed, the police must also be notified immediately.
Incident Reports
A business, property owner, property manager, or worksite supervisor may prepare an incident report after an accident. Request a copy and record the name and position of the person who received your report.
Photographs and Videos
Photographs and videos can preserve hazards, weather conditions, vehicle positions, visible injuries, and other details from the scene. If possible, save both wider views of the area and close-up images of the condition that contributed to the accident.
Witness Information
Write down each witness’s full name and contact information, even if the police or property owner also collected it. A witness may remember details that can help reconstruct the accident, but locating that person may be more difficult as time passes.
Property Damage Estimates
Repair estimates, invoices, and total-loss documents can establish the type and cost of damage to a vehicle or other property. Keep estimates from every inspection along with receipts for completed repairs or replacement items.
Insurance Documents and Correspondence
Insurance paperwork is more than administrative clutter. It creates a record of the information you provided, what the insurer requested, and how the company responded. Save copies of every form, message, and settlement offer, including attachments that may be easy to overlook.
Claim Forms and Claim Numbers
Keep a copy of each completed claim form and any documents you submitted with it. Record the claim number and the adjuster’s contact information somewhere easy to find so you can connect later correspondence to the correct file.
Letters and Emails From Insurance Adjusters
Save every letter and email from an insurance adjuster, even if the message seems routine. These communications may show the evidence the insurer requested, the records the adjuster reviewed, and how the adjuster determined fault.
Settlement Offers
Keep the complete written version of every settlement offer, including any proposed release or response deadline. An early offer may arrive before the long-term effects of an injury are clear, and signing a release could prevent you from pursuing additional compensation later.
Records of Phone Conversations
After each call, write down the date, the adjuster’s name, and the main points discussed. In a car accident case, you are not legally required to speak with the other driver’s insurance company, although your own policy may require you to cooperate with your insurer. An attorney can handle all communications with the insurer on your behalf.
Personal Records That Document Your Recovery
Medical records document what happened during a visit. They do not always capture what recovery looks like once you return home. A consistent personal record can preserve specific examples of how your injuries affect your comfort, independence, work, and relationships, providing context for your pain and suffering.
Pain and Symptom Journals
Date each entry and describe your symptoms in your own words. Note where you feel pain, how long it lasts, whether it interrupts your sleep, and how you respond to treatment. Regular, honest entries are more useful than trying to reconstruct several weeks from memory.
Changes to Daily Activities
Record the everyday tasks you have had to change, avoid, or ask someone else to handle. Specific details, such as being unable to carry groceries or sit through a child’s school event, show the practical effect of an injury more clearly than a general statement that life has become harder.
Missed Work and Personal Obligations
Keep a calendar of workdays, appointments, household responsibilities, and personal events you missed due to your injuries or treatment. You can also note occasions when you had to leave early, cancel plans, or rely on someone else to fulfill an obligation.
Digital Evidence You Should Preserve
Digital evidence can disappear with a deleted message, a damaged phone, or an overwritten recording. Save relevant emails, text messages, photographs, videos, voicemails, dashcam footage, and files from accident-related apps or online accounts. When possible, keep original files rather than relying on screenshots or versions downloaded from social media. Originals may contain dates, times, and other information that does not appear on the screen.
Back up important files in more than one secure location. Do not crop, edit, filter, delete, or fabricate evidence, even if something seems unimportant or potentially unfavorable. If you are unsure whether a file matters, preserve it and let your attorney determine whether it is relevant.
Personal Injury Document Checklist
- Medical records and treatment notes
- Medical bills and receipts
- Prescription records
- Police or incident reports
- Accident photographs and videos
- Witness information
- Insurance policies and claim documents
- Insurance correspondence
- Settlement offers
- Pay stubs and wage records
- Employer documentation
- Property damage records
- Personal injury and recovery notes
- Relevant emails, texts, and digital evidence
How Long Should You Keep Personal Injury Documents?
Keep accident-related records until your attorney confirms that they are no longer needed. Some documents may still matter after a settlement or verdict if medical bills, liens, or insurance issues remain unresolved. Confirm with your attorney before discarding originals or converting paper records to digital copies.
How Lever & Ecker Handles Evidence for Your Personal Injury Claim
Knowing what to save is not always straightforward, especially when records are spread across medical offices, employers, insurers, and other sources. Once you hire us, we will review the documents you have and identify what is missing. We will then request additional records on your behalf and take steps to preserve time-sensitive evidence, such as surveillance footage, before it disappears. We can even obtain documents that you may not have access to.
Our attorneys obtain and present evidence to prove how the accident occurred and establish the full extent of your injuries and other losses. When necessary, we also consult with experts, who can analyze the evidence and provide testimony to bolster the case. Our thorough approach has enabled us to secure more than $250 million in verdicts and settlements for our clients.
Speak With a New York Personal Injury Lawyer About Your Records
If you are unsure what to preserve, you do not have to sort through every document alone. Organizing the available records from the outset gives your attorney a clearer starting point and reduces the risk of losing important evidence.
At Lever & Ecker, our award-winning New York personal injury lawyers bring more than 80 years of combined experience to every case. For a free consultation to discuss your legal options, contact us online, call our White Plains office at (914) 288-9191, or call our Bronx office at (718) 933-3632.
