Clinical Records – A Key Document in an ICBC Claim

The vast majority of medical practitioners, whether doctors, physiotherapist, massage therapists or chiropractors, will be keeping notes of each visit you make to them whether it is before or after the accident. The notes are called clinical records.

The doctors and therapists in British Columbia vary dramatically in their ability to record complete and accurate clinical notes. Therefore, you are really at the mercy of the doctor or therapist in terms of whether they are accurately and completely recording what you are telling them.

The unfortunate part is that ICBC spends a tremendous amount of effort obtaining all the clinical records of any doctor or therapist you may have seen both before and after the accident. ICBC will go through the clinical records in great detail and will try to find inconsistencies, lack of reporting, information that will minimize your claim, etc.

Although you do not have control over whether your doctor or therapist is a good note-taker, you should at least give them the opportunity to record complaints by being as accurate and complete as possible in your self-report to the doctor/therapist. Your only hope is that much of what you are telling the doctor/therapist is making its way accurately into the clinical records.

You should go on the assumption that if you tell your doctor or therapist about something, it will show up in the clinical records and ICBC will eventually see it. This is because the doctor or therapist has a duty to ensure that everything significant is recorded in the clinical records.

If ever questioned by ICBC or the defense lawyer on certain notations in the clinical records, you do not have to agree that you told the doctor or therapist the particular entry if you did not. We all know that everyone is human and errors will be made regularly especially when the doctor or therapist is running a very busy practice.

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