The ER doctor asks how you’re feeling. You say “sore but okay.” Three days later your shoulder pain is unbearable. Your attorney requests your medical records. The ER note says: “Patient reports feeling okay, mild soreness.”
That one sentence can reduce your settlement substantially – practitioner experience shows documentation inconsistencies commonly reduce settlement value by 20-40%. The at-fault driver’s insurer will argue you exaggerated your injuries – if you were “okay” at the ER, how can you now claim serious injury? Medical records are evidence. What goes in them shapes what comes out of your claim.
Most riders don’t realize their words to medical providers become permanent documentation that insurers will use against them. This guide shows you what actually gets recorded, why it matters under Georgia’s comparative fault system, and how to ensure your medical records support your claim rather than destroy it.
What Medical Providers Actually Write Down
Medical records follow standardized formats. Understanding what gets documented – and how – is the first step to protecting your claim.
Chief complaint: Your answer to “What brings you in today?” This goes in the record verbatim or paraphrased. “I’m fine, just checking to be safe” becomes “Patient denies significant injury.” “I was in a motorcycle crash and my back hurts” becomes “Patient reports back pain following motorcycle collision.”
History of present illness: The narrative of what happened. Providers ask how the crash occurred, what you felt immediately after, and what symptoms you’re experiencing now. Every detail gets documented. If you say “I think I was going about 50,” it goes in the chart. If you say “I’m not sure who was at fault,” it goes in the chart.
Physical examination findings: What the provider observes. Visible injuries, range of motion limitations, areas of tenderness, neurological function. This is objective evidence – harder for insurers to dispute than your subjective complaints.
Assessment and diagnosis: What the provider concludes is wrong with you. This drives treatment and becomes the foundation of your injury claim. “Contusion” is minor. “Grade 2 AC separation” is significant.
Treatment and plan: What was done and what should happen next. Discharged home with ibuprofen is different from admitted for observation, which is different from referred to orthopedic surgery.
Patient statements about pain: Pain scales (0-10), descriptions of pain (sharp, dull, constant, intermittent), and what makes it better or worse. These create the baseline for tracking injury progression. If you rate pain 3/10 at the ER and 8/10 three days later, insurers argue you’re exaggerating – unless the medical record explains why (inflammation worsened, additional injury discovered).
Georgia providers increasingly use electronic medical records (EMR). These include templates with checkbox options. Providers click boxes quickly during evaluation. Sometimes they click the wrong box. Sometimes they don’t update a previous entry. Errors happen – and they become part of your permanent record.
The Adrenaline Problem
After a motorcycle crash, your body floods with adrenaline and endorphins – natural stress hormones that temporarily suppress pain perception. Medical literature documents this effect can last hours or even days.
You genuinely feel “okay” at the crash scene. You genuinely feel “fine” at the ER two hours later. The provider documents: “Patient denies significant pain.”
Three days later, adrenaline wears off. Inflammation sets in. Soft tissue damage that was masked by your body’s stress response now screams. You can barely move your neck. Your shoulder throbs. You return to the ER or see your primary care physician.
The new provider compares current complaints to the initial ER visit: “Patient now reports severe neck and shoulder pain, though initial evaluation noted no significant complaints.”
Insurers read that as inconsistency – therefore exaggeration, therefore reduced settlement. They’ll argue you weren’t really injured in the crash; something else happened in the three days between visits.
This is why communicating the adrenaline effect to providers is critical. Tell them:
“I know I said I felt okay initially, but I’ve read that adrenaline can mask injury pain for the first few days. I’m starting to feel things I didn’t notice right after the crash.”
That statement gets documented. It explains the progression. It preempts the insurer’s exaggeration argument.
What to Say (and Not Say) to Medical Providers
Medical providers are treating you, not advocating for your legal claim. They document what you tell them without considering how it sounds to an insurance adjuster. Your job is to be honest about your injuries while avoiding statements that create legal problems.
Say this:
“I was in a motorcycle crash [date]. I’m experiencing pain in [specific locations]. The pain is [describe: sharp/dull/constant/comes and goes]. It’s worse when I [specific activity]. I’m concerned because it’s not improving / it’s getting worse.”
Don’t say this:
“I’m fine, just want to get checked.” → Documents as minor or no injury.
“It doesn’t really hurt that bad.” → Documents as mild pain, contradicts later severity claims.
“I probably should have braked sooner.” → Fault admission, goes in the chart, insurers will find it.
“I think I’m okay to go back to work tomorrow.” → Suggests injury isn’t limiting, contradicts disability claims.
“The other driver ran the red light, it wasn’t my fault.” → Liability narrative in medical record is irrelevant to treatment and can be misquoted.
Describe pain accurately:
Providers use pain scales (0-10, where 0 is no pain and 10 is worst imaginable). Be honest. If you say 2/10 to avoid sounding dramatic, the record says your pain was minor. If it’s actually 7/10, say 7/10.
Describe functional limitations:
“I can’t lift my arm above shoulder height.”
“Turning my head to check blind spots causes sharp neck pain.”
“I can’t grip the brake lever with my right hand.”
These are objective, measurable limitations that explain why the injury matters. They’re more powerful than vague “it hurts” statements.
Report all injuries, even minor ones:
You notice some road rash on your leg. It seems trivial compared to your shoulder pain, so you don’t mention it. The provider documents only shoulder injury. Later, the road rash gets infected. Insurer argues the infection wasn’t crash-related because it’s not in the initial medical record.
Report everything. Let the provider decide what’s significant. If you’re not sure whether something is related, say: “I also noticed [symptom]. I don’t know if it’s from the crash, but I want it documented.”
Explain pre-existing conditions honestly:
You had lower back pain before the crash. The crash made it worse. If you don’t disclose the pre-existing condition, the insurer will find it (they pull your entire medical history). If you do disclose it, explain: “I had occasional lower back stiffness before the crash, maybe 2-3/10 pain. Since the crash, it’s constant 7/10 pain and I can’t bend forward.”
This documents that the crash aggravated a pre-existing condition – which is compensable in Georgia. Hiding it makes you look dishonest and gives insurers ammunition to deny the entire claim.
Treatment Gaps Kill Claims
“Treatment gap” means time between medical visits with no documented care. Insurers use gaps to argue your injury wasn’t serious – if it hurt that much, why didn’t you see a doctor?
Industry data indicates that treatment gaps of more than two weeks can reduce settlement value by 30-50%, with EvenUp’s research showing that maintaining consistent treatment can increase settlement value by approximately 20% per case. Gaps longer than a month may kill the claim entirely.
Common gap scenarios and how insurers exploit them:
Scenario 1: You go to the ER immediately post-crash. Doctor says “follow up with your primary care physician in one week.” You feel better after a few days and don’t follow up. Three weeks later, pain returns. You finally see your PCP.
Insurer argument: “Three-week gap proves injury resolved, then something unrelated caused new pain.”
Scenario 2: You see your doctor consistently for three months, then miss two months because you’re busy with work, then return when pain worsens.
Insurer argument: “Two-month gap shows patient wasn’t actually in pain or they would have continued treatment.”
Scenario 3: Doctor refers you to physical therapy. You go to two sessions, then stop because it’s expensive / time-consuming / doesn’t seem to help immediately.
Insurer argument: “Patient abandoned prescribed treatment, therefore injury wasn’t serious.”
How to avoid treatment gaps:
Follow provider recommendations: If the ER doctor says “follow up in one week,” follow up in one week. Even if you feel better. The visit documents that you’re improving – which is good. Skipping it creates a gap – which is bad.
Document why you missed appointments: Life happens. You get sick with the flu and can’t make your PT appointment. Work demands make it impossible to take time off. You lost your insurance. Whatever the reason, document it in writing when you reschedule: “I had to cancel my March 15 appointment due to [reason]. I’m rescheduling as soon as possible.” The provider notes this in your chart.
Communicate financial barriers: Physical therapy costs $150 per session, three times per week. You can’t afford it. Tell your doctor: “I want to do PT, but I can’t afford the recommended frequency. Can we modify the plan?” They may reduce frequency, find a cheaper provider, or note the financial barrier in your chart. That note explains the gap.
Continue treatment until released: Don’t stop because you feel better. Continue until the provider says “you’re healed, no further treatment needed” and documents it. That’s medical release. Stopping on your own is treatment gap.
Getting Your Own Records
You’re entitled to copies of your medical records in Georgia. You need them for three reasons:
- Accuracy check: Providers make mistakes. Names, dates, body parts (left vs right), pain descriptions – errors happen. Catch them early.
- Attorney review: Your attorney needs complete records to evaluate your claim and identify what supports it vs. what creates problems.
- Insurance submission: You or your attorney will submit records to support settlement demands.
How to request records:
Each medical provider (hospital, ER, primary care physician, specialist, physical therapist, imaging center) maintains separate records. You request from each separately.
Contact the provider’s medical records department (usually listed on their website or by calling the main number). Ask for:
- Complete medical records from [date of crash] to [current date]
- Include: Visit notes, diagnostic reports (X-rays, MRIs, CT scans), lab results, prescriptions, discharge summaries, billing records
- Format: PDF via email or physical copies
Cost: Georgia law allows providers to charge reasonable fees for copying records. Typical range: $0.25-$0.75 per page, plus administrative fees. Digital copies are often cheaper or free.
Timeline: Providers must respond within 30 days of your request. Some respond faster; some use the full 30 days.
Authorization forms: Most providers require you to sign a release form. They’ll send it to you, you sign and return it (often can be done electronically).
What to look for when you receive records:
Factual errors: Wrong date, wrong body part, wrong mechanism of injury (record says “car accident” when it was motorcycle), wrong medications prescribed.
Inconsistencies: One note says pain is 7/10, another from the same visit says 4/10. One says left shoulder, another says right.
Omissions: You told the provider about neck pain, but the record only documents shoulder pain.
Harmful statements: “Patient admits fault,” “patient was speeding,” “patient reports alcohol use prior to crash” (even if you had one beer with dinner three hours earlier, it gets documented and insurers weaponize it).
If you find errors, you can request amendments. Write to the provider’s medical records department:
“I am requesting an amendment to my medical record dated [date]. The record states [incorrect information]. The correct information is [correction]. Please update the record and provide me with written confirmation.”
Providers aren’t required to make amendments, but many will if the error is clearly factual (wrong date, wrong body part). They’re less likely to amend subjective statements or clinical judgments.
Even if they refuse to amend, your request becomes part of the record. Your attorney can use it to argue the record is unreliable.
Imaging and Diagnostic Reports
X-rays, MRIs, CT scans, and ultrasounds are objective evidence. They show what’s actually damaged, not just what you report feeling.
X-rays: Bones, fractures, dislocations. Don’t show soft tissue (muscles, ligaments, tendons). ER usually does X-rays first because they’re fast and cheap. Negative X-ray doesn’t mean you’re not injured – just means bones aren’t broken.
MRI (Magnetic Resonance Imaging): Soft tissue, ligaments, tendons, muscle tears, disc herniations, nerve impingement. More expensive, takes longer to get approved and scheduled. Most valuable for proving non-bone injuries.
CT Scan (Computed Tomography): Bones and organs. Better than X-ray for complex fractures, internal bleeding, organ damage. Common in ER for head trauma evaluation.
Ultrasound: Soft tissue, blood flow, fluid collection. Less common for motorcycle crash injuries unless checking for internal bleeding or deep tissue damage.
Radiology reports:
Imaging studies generate two outputs:
- Images: The actual scans/films
- Radiology report: A radiologist’s interpretation of what the images show
The report matters more for your claim than the images. Most people can’t interpret an MRI – insurers rely on the radiologist’s written findings.
Key terms:
- “Unremarkable” = normal, no pathology found
- “Consistent with” = the finding matches what you’d expect from the reported mechanism of injury
- “Age-related changes” / “Degenerative changes” = pre-existing wear and tear, not caused by the crash
- “Acute” = recent, likely crash-related
- “Chronic” = long-standing, pre-existing
If the report says “acute grade 2 AC separation consistent with reported trauma,” that’s strong evidence. If it says “mild degenerative changes, no acute findings,” that’s weak evidence.
Get copies of both images and reports. Your attorney may have them reviewed by an independent radiologist if there’s a dispute about findings.
Long-Term Follow-Up
Some injuries don’t fully reveal themselves for months. Concussion symptoms that persist beyond initial recovery. Post-traumatic arthritis in a previously fractured joint. Chronic pain from soft tissue damage.
If you settle your claim and sign a release, you can’t reopen it when these long-term effects appear. Medical records documenting potential long-term complications protect your ability to negotiate for future damages.
What to ask providers to document:
“Is there any risk of long-term complications from this injury?”
“Could this injury cause chronic pain or require future treatment?”
“Will I need ongoing monitoring or additional procedures?”
If the answer is yes, make sure it gets documented. Your attorney uses this to argue for compensation beyond current medical bills – to cover future treatment you’ll likely need.
Before You Leave Any Medical Appointment
Check that the provider documented everything you reported. Ask: “Can you confirm you noted my neck pain, shoulder pain, and difficulty sleeping?” If they say yes, you’re covered. If they say “Oh, I forgot the shoulder pain,” they can add it before finalizing the note.
Get copies of all visit summaries, discharge paperwork, and prescriptions. Don’t rely on providers sending them to you later.
Ask for the next appointment before leaving. Don’t create a treatment gap by assuming you’ll call later to schedule.
Your medical records are evidence that will either support or sink your claim. Every visit, every word, every gap – it all gets scrutinized. Treat medical documentation as seriously as crash scene photos. Both are building your case, one sentence at a time.
Disclaimer: This article provides general information about Georgia motorcycle accident law and is not legal advice. Every case is different. Consult a qualified Georgia motorcycle accident attorney to discuss your specific situation. Nothing in this article creates an attorney-client relationship.