Huntington Beach Spinal Cord Injury: Records and Review Questions

Three tasks for a useful file

1. Step 1

   Keep the clinical terms and their dates intact

   NINDS describes spinal cord injuries by location and severity and explains that functional effects vary. Use the wording in the treating team’s records rather than converting back pain, a scan finding or a family description into a different diagnosis.

   • List each treating facility and the dates of care.
   • Separate imaging reports from the image files themselves.
   • Flag conflicting descriptions for the clinician instead of resolving them yourself.

2. Step 2

   Document daily assistance and rehabilitation

   Keep the written rehabilitation plan and dated notes about actual assistance with mobility, personal care, transportation or work. A record of help provided differs from an expert estimate of future needs. Keep those categories separate.

   • Record who provided assistance, the task and the date.
   • Retain equipment prescriptions, invoices and modification estimates.
   • Keep work restrictions and vocational recommendations with their authors.

3. Step 3

   Match the incident record to the event

   A traffic collision, fall or workplace event in Huntington Beach may involve different agencies and organizations. Identify the actual custodian from the incident documents. The nearby hospital or city name cannot establish who investigated or who may be legally responsible.

   • Preserve scene photographs, witness information and report references.
   • List missing records and the organization believed to hold each one.
   • Ask counsel to assess deadlines and parties from the facts, including any government involvement.