Medical Documents in Personal Injury Cases
If you have been injured as a result of any type of accident and are claiming compensation, a major aspect of your case will be to prove your injuries, treatment, recovery, prognosis and disabilities. The person you are claiming damages from is entitled to obtain and review your medical history and it is not uncommon for the defendant to ask for all of your medical files / records going back at least 5 years prior to the accident. In reviewing the medical records, the defendant’s lawyer will consider many things, such as historical health, any pre-existing injuries, prior accidents and whether the injuries complained of in the accident are old or new injuries.
Obtaining medical records also assists your own personal injury lawyer to support your injuries, explain treatment received, assess the impact of any pre-existing injuries and prove any permanent disabilities caused by the accident.
Under Ontario law, all relevant documents (including medical records) must be exchanged between parties in court actions. It might seem intrusive to have to share all your medical history and documents, but it is the law.
Your lawyer will on your behalf obtain a variety of medical records. The list includes clinical notes and records, medical reports, diagnostic results, medical-legal reports and so on. In support of your case, your personal injury lawyer will submit into evidence at trial clinical notes and records completed in the ordinary course of business. This is called business records (your medical records) under the Ontario Evidence Act (currently under section 35). This allows your lawyer to refer to the records without having to call each and every doctor or health care provider who authored the documents. If the opposing party objects, the doctors (authors of the records) will need to be called as witnesses at trial. 
In most cases, your personal injury lawyer will call at least two types of health care providers at trial, your treating physician, usually your family doctor who will give evidence of his observations, diagnosis and treatment provided. In doing so, your doctor will refer to his clinical notes and records in your file. Your injury lawyer can and usually does also calls expert medical evidence by calling a medical expert who has met and assessed you and has an expert opinion to convey to the court on various aspects of your injuries and medical condition. In such a case, the expert usually refers to his own expert report during his evidence prepared well in advance of the trial and provided to the opposing party.
The opposing party may also call their own expert medical evidence. The opposing party could send you to their own experts for assessment. This is called a defence medical examination. This process happens prior to trial and if the defendants does call an expert, they must also comply with the formal notices and time-lines under the Ontario Evidence Act and Rules of Civil Procedure.
Finally, your own oral evidence would be called to explain the facts of the accident, your injuries and the impact on your life. Here you can explain based on your own experiences and observations how the accident impacted your life. It is important that your evidence is consistent with the medical evidence.
If you have been injured in an accident and claim compensation, your medical history will be open for review. The medical evidence is central to all injury cases. You should consult an experienced personal injury lawyer as soon as possible if injured so that he/she can assist you in determining what medical evidence is needed to fully support your injury claim.
Consultations are free and our lawyers work on the basis of no fee until you win
Marc-Nicholas Quinn
Ottawa Injury Lawyers
Ottawa, Ontario
Tel: (613) 315-4878
The content of this article is intended to provide a general guide only and is not intended to be legal advice. You should consult an injury lawyer who can review the facts of your particular case.