Hi everyone. Welcome to an introduction to dissection of medical records. My name is Debra Lee Doby Munster. I am a partner at Vaughan and Baio. And I was previously a senior partner at an AMLAW 200 firm. I have been practicing for over ten years and I am also the founder of the Misunderstood Lawyer Project, which provides free advice for those individuals that are in law school young associates. So it's job related advice of how to get a job and move forward. And so if you have questions about this lecture or anything in general in terms of the law, you're more than welcome to reach out to me at misunderstood lawyer at gmail.com or at social media. Before we get started, I have to do my usual disclaimer, which is that I practice solely in New York. If I use an example, or if I mention a specific forms or medical records or whatever it happens to be, It's all related to New York. But this is going to be an introductory course into how to approach medical records. But it cannot be construed as providing any legal advice. So if you have questions, please reach out to me and I'm happy to help. So with that, let's get started. So we're going to be talking today about the role of medical courts in litigation and why is that important. And it's really important for you to understand that the value of your claim of whatever, whether you're on the plaintiff or defense side, the value of your litigation is tied directly to the impact. Of an injury on an individual, which means we're going to be looking at whether the person has loss of wages. We're going to you need to know whether or not they have lost time from work, whether or not they have lost lots of medical treatment or little to no medical treatment. So this is talking about how the role of specific medical reports are going to either increase or decrease the value in your litigation. Now, the. Title of this indicates that this is for worker's compensation. This introductory course can be for worker's compensation or general litigation. It can be a broader sense. So we're going to be looking at trying to expand your knowledge of how to start using medical courts in litigation. Now, we're also going to be talking about how you've got to increase your vocabulary of medical jargon. And medical jargon is basically anything that a doctor says in a medical report. And we're not doctors. So we have to understand that we can't second guess the physicians on what they're saying. We can't second guess them on terms of their treatment recommendations or options or how that impacts an individual. But what they say in the medical report is something that we have to learn and understand how to interpret what they're saying. And the way that you do that is you start by researching the terms. So if you come across something that you don't understand, then you have to research it, figure it out, and it slowly you build up a bank of medical jargon. And that certainly helps with your ability to more efficiently process medical reports. Finally, we're going to talk about the understanding, the relationship between your specific litigation, the facts of that claim and the medical reports and why that matters. Okay. So since this is an introductory course, where we're going to start is the actual medical records themselves. How do we get them and what are we going to do with them? Okay, but why are we even discussing this? And basically, I can tell you that any suit that involves an injury to an individual from personal injury, medical malpractice, worker's compensation and Social Security all depend on medical records. A plaintiff has to support their allegations with medical evidence. So, for example, if a plaintiff files a pleading alleging that he was in a motor vehicle accident and he injured neck, back head, shoulders, feet, knees and his head. And the medical reports only indicate that he has ongoing pain in his neck. Well, then there's really no value or substance to the other injuries. Sure, you can list them in your pleading, but it's not going to increase the value of that claim. And it's really important for plaintiffs and defense counsel to understand the value of the claim when you're looking at it in terms of settlement or whether you should go to trial or how to value your claim in order to settle it. Now there are common claims for anything that's involving an injury. You're looking at compensatory, nominal and putative. So compensatory just simply means that, hey, you're paying a person back for the the medical treatment or lost wages that they've already had. Nominal means that they're an injury may have occurred, but it hasn't permanently impacted your life in some way. And then, of course, there is punitive, which means something seriously terrible has happened. And the courts may look at imposing a punitive damages on an individual to prevent that type of activity from going on in the future. But when we're looking at claims for damages, you're looking at medical costs, both current and future. You're looking at whether there is a claim for pain and suffering and whether that claim is supported. More importantly, loss of consortium, which is which is a fancy term for meaning, loss of sexual relationships between partners. And those are the damages that have to be supported by medical records. And it will directly impact the value of your claim because current and future medical treatment equals exposure every single time. And exposure is the fancy legal term for saying how much a case is worth and how much should we be settling for. If after trial, how much is the case is going to be worth? Um, I was involved in part of a general litigation where the plaintiff was severely injured by a fall off of a scaffolding. And the. The fall was not a dispute. His current and future medical treatment. His current medical treatment was not in dispute, but his future medical treatment, his loss of wages. All of that was in dispute. And so while we knew we were going to lose the case, right, the plaintiff's demand was. $32 million. And after we went to trial, the plaintiff was only awarded $12 Million. So for our client, that was actually a win because it saved them several million dollars. So it's all about what you're seeing as your exposure and you're looking at the or always focused on the value of your lawsuit. Okay. Now, since this is an introductory course, I want to start off at the very basics of what you need to do to evaluate medical reports. But in order to evaluate medical reports, the very first thing you have to do is get them. You have to secure them. Okay? And to do that, you're going to need what we call a HIPAA release. And HIPAA means Health Insurance Portability and Accountability Act. Now, that's a long. Title. That simply means it is a federal. Act that sets a floor of privacy protections and rights for individuals to control their own health care data. So previously, before this act was enacted, it was really difficult for individuals to access their medical records. And if the medical records contained information, information that was incorrect, those individuals never saw those medical records and could not change them or seek a correction. So the HIPAA Act allows individuals to access their medical records, but it also prevents what a covered entity like a hospital or anyone that provides medical services to comply with HIPAA, which means they cannot distribute it to a third party without the express permission of the individual. That means that if a plaintiff undergoes a lawsuit and we're seeking medical records for that plaintiff, we can't get them without his express permission. And he is required to do litigation to provide those records to those releases to us. But there are tricks in and delay tactics for providing those releases. And we'll go over that in just a minute. So the hippo release is really important, but I want to make something very specific. Hipaa is the floor. Okay. The federal floor that affords privacy protections for individuals in their seeking medical treatment. Okay. The floor. Different states, especially California and New York, have increased protections that you may need to comply with. So you definitely need to check your state to see if there is a specific or more advanced form hip form that is required. Additionally, specific hospitals will have a specific release that is just to the hospital. And so you may well there are a bunch of generalized forms that you can use for the plaintiff to sign to give you to get HIPAA. You will also need to be looking at where do they treat and do those hospitals have specific forms? Because then you're going to need the plaintiff to sign those specific forms as well. Okay. So obviously, you need the HIPAA release in order to get those medical records. But that promotes a second question from who are we requesting these medical records from? And the plaintiff should be disclosing a list of providers that have treated them for all the injuries claimed. Now, that's really important because it has to be relevant information. Okay. So if you are a individual. Um, that was in a, let's say, a motor vehicle accident. And you're injured. You're alleging injuries to your neck and your back. Right. And you had a prior shoulder surgery. Your attorney may not think that the shoulder is relevant and you don't need to disclose that provider because there is no treatment to the neck or back. If you are on the defense side, you are going to want to see those medical records for the shoulder, although they may not be relevant to the the litigation on the neck of the back, it may disclose whether or not he had prior neck problems because it's related. So there might be an argument over what is relevant. Okay. But certainly, if it is claimed in the lawsuit, it is certainly relevant and the plaintiff should be providing and disclosing a list of providers. If you're on the defense side, you can also do what we call a medical canvass search, which means that you are looking at you were hiring a company to call every hospital and urgent care within a 25, 50 or 75 mile radius and check to see if this individual showed up at their facility. And if so, then we have a list of possible records that we want to go get and we'll have the plaintiff sign additional releases for what? For the information that we've uncovered that they didn't provide. Now. You may be thinking. Well. A plaintiff should always provide. Every provider will. Yes, they should. But also keep in mind that people are not. Entirely great historians. People are going to remember if they ever treated an urgent care for a cold or a neck pain that lasted for two days. That may be relevant for our litigation, but it's not necessarily that the plaintiff is going to remember when they're saying, hey, have you ever provide a list of providers? They're mainly going to include the main people they see like their primary care. So just keep in mind that, you know. The plaintiff may not be trying to be untruthful. It's just the fact that, you know, we're not we're poor historians when it comes to our own medical records. Um, now you're also going to want to pay attention to these forms. So in terms of plaintiffs attorneys, you want to make sure that you don't provide a generalized broad HIPAA without a specific end date. Typically in litigation, the end date is end of litigation. I have seen some plaintiffs attorneys who only provide it for six months. And in order to as a delay tactic, but most plaintiffs attorneys provide it to the end of litigation. Defense attorneys, you need to make sure that the form is properly filled out, that you mark off the correct boxes and we'll show you an example in a minute. But it doesn't exclude any relevant information. You also need to make sure that it identifies an appropriate third party to receive those records and whether that be your law firm or the insurance carrier or whomever it happens to be. It needs to be listed because if it's not, you're not going to get those records. And that ends up being a problem. And again, plague attorneys do use. They do fill out the forms incorrectly as a delay tactic. Okay. Now, this is as I said, as I mentioned previously, I practice solely in New York. And so I'm showing you the HIPAA that is related to New York State Department of Health. That is the common form that most that we use to secure medical records. I will say that there are certain hospitals that will not accept this form because they have a specific release. You will need to then when you disclose, they will you will communicate with the hospital. Hey, here's a form. Please give me these records. They will come back to you and say, Um, while we would love to give you these records, we don't accept this form. Please have the individual fill out this specific form and they will provide that to you. And then you can send it to the plaintiff's counsel to have them sign a separate form for that particular hospital or facility. Okay. Now, I will also let you know that most of the time attorneys are really bad about the fact that we don't really look at boilerplate language that much. But when you're starting out, understanding what the HIPAA form actually provides is really important for your practice of law and you building your knowledge. So you need to understand that this authorization may include the disclosure of information relating to alcohol, drug abuse, mental health treatment, medical treatment, except psychotherapy notes. If you want psychotherapy notes, you have to have a completely different form. You need to understand that. Additionally, if you want alcohol, drug abuse or HIV, you're going to have to specifically list it in this form, and we'll show you that in a minute. Okay. The plaintiff always has the right to revoke this. And more importantly, you cannot re disclose this information. And that's really important. So under Box six through 12 is really where the information that you've got to double check that the name is there. So number one, it needs to be the name and address of the health provider. Um, typically plaintiff's attorney just give you they don't fill out 7 or 8. They leave that to the carrier to fill in because you need the official name of the health provider and pledged can't be bothered to do so. Um, but so you need the proper name, official name of the health provider and their address. And then. Then you got to click this medical the specific information to be released. And this is where if you're playing attorney, you're going to limit it as much as possible. So if you're playing attorney, you're going to want it to limit the medical record from the date of the incident forward. You don't want to give them anything previously, If you're the defense counsel, you're going to be asking for the entire medical record. And that's an argument that you can have with plaintiff's counsel and see what comes out. Typically, I get the entire medical record. Just by asking. And then. But if you want anything related to alcohol, drug treatment, mental health information or HIV related, the individual is going to have to sign those specific boxes without signing those boxes. You don't get that information. It's automatically excluded. Okay. Um, the other is authorization to discuss health information is where you authorize them to discuss and also release the information. And this is where you have to put the name of your firm in or the insurance carrier or whatever entity is going to be receiving these medical records. That way they will the the hospital will be authorized or the provider will be authorized to send these records to you. That's really important. Sometimes it's left blank for you to fill it in and which is nice. And sometimes they'll list the carrier and not the law firm. And that is again, a delay tactic. Um, so the date on which this authorization expires, if you are a plaintiff's attorney, you are really looking at when this authorization will expire. And you should typically be in of litigation. That's the easiest way to do it. But sometimes you can limit it to six months or one year, depending on how much of a hard time defense counsel is giving you. And then it's got to be signed and dated. And if it's not the patient, let's say the patient is comatose or or has passed away, you need the name of the person that's authorized. That person either has to have a power of attorney or has been appointed by probate or to sign the form on their behalf. Okay. So this form is really important to actually secure those medical records. Now, once. You get those medical records, the most important thing to do is organize the medical records appropriately. And the one thing that I can just please do is that if you have your own practice or you always want to mark the medical records that come in as original and you always want to then keep those in a separate place and do not touch them, you want to make copies of those medical records for analysis and comments and thoughts for your paralegals to go through or you to go through the medical records and make comments on. Because I cannot tell you the number of times that there has been an accidental disclosure of a of an attorney's private analysis, confidential analysis to the courts or other parties because they weren't paying attention to the medical records that they actually sent to the court. So it's really important for you to keep those medical records separate. Additionally, the role of paralegals and medical records is paramount. So if you're working for a larger law firm, usually over 100 or 200, you're going to have paralegals that. Track down. Obtain and secure. Medical records. Okay. The paralegals are also going to do an initial assessment of those medical records and give you either a PDF that's that that's appropriately marked or written up, or it's an Excel spreadsheet or a word document. Some some firms do word documents. Well, I have no idea, but. The. The reason that large law firms allow the paralegals to do this is because if you're especially on the defense side, the insurance carriers won't pay for attorneys to do the initial processing of medical records. But if you work for a smaller firm, you know, under 50 or if you are a solo practitioner, it is going to be your job to go get those medical records. It's your job to do the initial analysis. And if you're thinking, Well, I'm going to work for a big law firm so I don't have to learn this, that's not true. First of all, there are different types of paralegals. Some are good, some are bad, some are phenomenal. And they do a much better job than you. But you have to learn your paralegal and figure out, are they on task? You have to look at their work product and be able to make sure. But when you're preparing for trial or a deposition, you're going to have to go through these medical records yourself. And so and and some paralegals miss a lot. Some don't. I worked with a paralegal that did a better job than most attorneys. So it just depends on who's doing the job and and how well the job is done. So you still need to understand how to go through these medical records. Okay. Now, the first place. You always start and I know it seems weird is you're just going to dive into the medical records, but you don't. You need to understand the claim first. And that's where you always start. You always start with the claim. What is the plaintiff claiming? Or if you are the plaintiff, what are you claiming? And what can you claim based off the medical records? And the first thing that you want to look at if you're on the defense side is the jury instructions and you want to look at the burden of proof that's required to meet every allegation. The next thing you want to look at is the plaintiff's pleadings. What are the claims, what are the allegations? How did it happen? And then if you're on the defense side, you're going to go back to your client, either the carrier or the employer or the other party, and you're going to look at incident reports, investigations, informal discussions. What is their interpretation of what happened, um, prior to formal depositions. And then you're really going to be looking for red flags. You're going to look to see if depositions of the plaintiff or the witnesses have already been done. And then, of course, you're looking at whether or not the medical records have been secured and have we got them from everywhere or are we still missing medical records? You'd be surprised at the number of times just before we go into a plaintiff's definition, all of a sudden we've got to postpone the plaintiff's definition because we're still missing medical records and we can't conduct the depositions of the plaintiff without having those medical records. Or you shouldn't. Now you also need to. So first of all, you've got to understand your claim. The second thing you need to do is focus on the facts of the claim and sorry for the awesome pun there, but you really need to put on what I call your detective hat and really look at the who, what, why, when and where. Okay. Those are the main questions that we're looking at. Who's the plaintiff? What is his job? How did the injury occur? What is the exact mechanism of injury? And if you're curious on what mechanism means, mechanism means is what exactly happened in the alleged injury. So, for example, let's say that it's a slip and fall, okay? That you're in a movie theater, the person slips and falls and is alleging that they have their right knee surgery is because of that slip and fall. Well. You're looking at the exact mechanism. So when you're cross-examining the plaintiff, what you want to know is how did you fall? Did you fall directly onto your knee? Did you fall all the way down? Was the floor wet? You're really going to be looking at the mechanism like, what were you doing prior to and walking them through? What were you doing when you left the theater? What movie did you see? How was it? What time did it end? When you were walking out? Were you talking to anyone? Were you looking at the floor? These are the things that you're going to be wanting to know. That's an exact mechanism. So when they fall, the mechanism is how did they fall? What did they fall on? What body part was directly injured? How did they get up? That's the mechanism of injury. Then you want to know. When was the actual first hospital treatment? Because if it's the day of the accident that supports the plaintiff's claim that something happened. If it's months later, it detracts from their claim. It doesn't support them. So and then you want to see where is the first hospital treatment? Let's say that they tripped and fell in a movie theater in Manhattan and then they went all the way home and treated in, you know, southern New Jersey next to Atlantic City two months later. Well, that's a little strange, isn't it? So you want to not only pay attention to the Who, but also where and why and when. Okay. Because context matters. Because before you go to look at the medical reports, you've got to understand the context and we'll show you why it matters later. Okay. So in terms of the medical reports, you're going to be looking at personal details, but we're looking at it from the point of what is the allegations. And if you're on the plaintiff's side, you're really going to be looking at the medical records, too. What can we put into this pleading? What can we claim or allege and how can we bump up the value of our claim? Okay. Now, here's an example of a fact pattern. I'm not going to read. Everything because it's obviously people can read. But here is the fact pattern. And this is going to show you what is the difference in the facts and why it's important for you to understand the facts before you dive into the medical records. So in terms of your fact pattern, construction worker Bob in Manhattan alleges falling off a ladder because bricks fell onto his head from above. On September 18th of 2021, Bob was held up by Jose, a coworker, and he went to sit in his car for the remainder of his shift. He did not seek ambulance or emergency room treatment at that time. He continued to work for the same employer until the pain got too great and he called out sick and he specifically told the employer that he could not work because of the September incident. He did not seek medical treatment until November 10th of 2021. And then Bob was eventually fired for failure to return to work. Um. Because he. Was injured. Now. We represent the employer. So, you know, you talk to the employer. And what is their response? Their informal response was that he was a troublemaker. He caused several heated arguments on the site. There were a couple of fistfights, fights he was hired for only one week prior to September of 2021 to help clean up a job site. There was no active construction being done on September 18th, but the job site was open. Then the employer advised Bob that. Hey, you're done, you're let go. And he was let go on September 20th. Um. No one knows. Anything about the accident. They did ask Jose if anything happened, and Josie said that he didn't see anything happen. But he doesn't want to be involved. He doesn't wanna be cross-examined because they're friends. So he does. He's just not going to answer any questions about it. So that is the typical scenario that we get where it's pretty divergent, you know, like this is what happens. I got I got and everybody knew about the injury versus nothing happened. And he was a troublemaker. So then we. Literally on a legal. Pad, you're going to. Write down what are the consistencies and what are the inconsistencies. Okay. So first and foremost, a consistency is both say that, hey, we were hired, there was. An employee employer. Relationship. Great that he worked for the employer. Um, and that he was released from employment on September 20th although. Obviously, Bob's alleging he was fired. And then, you know, the employer saying, well, no, the job just ended. You know, he was just let go because there was no more work. And there's a possible injury on September 20th. Um, now, factually, it. Says he worked for one week and had issues with the employer. Those may be consistent, but we're not entirely sure we want to investigate those. So factual inconsistencies just from the fact pattern that we've been given, like straight off the bat is that there's no emergency room visit until November of 2021. The worksite was allegedly closed on September 18th, but there are logs that demonstrate the claimant worked on the date of injury. So he was there and he worked. So the was there active construction being done. So that's the question. So. An employer may say there's no active construction being done, but. It was still open for cleanup, which means he worked that day. So it doesn't matter if there's active construction. He was there. He worked eight hours. He got paid for eight hours. There is a New York. Department of Building Completion certificate and is certified for September 21st of 2021. That tells you right then and there that, hey, the work was done. So when they were let go, the job was over. So it didn't continue after September 21st. Factual inconsistency. Josie may not. Back up the claimants stories. Okay. And then a factually consistent would also be the claimant signed logs on September 18th and 19th, and he checked the box that he didn't have an injury that occurred on that day. So that's also an inconsistency. So when we're looking at the medical reports, we're going to be going through with it to see what was claimed, what was the problem? Now let's look at the initial emergency room visit on November 10th. The patient indicates he fell off a ladder while cutting a tree branch that is completely different than bricks falling on your head. He denies loss of consciousness, denies anything falling on top of him. And the examination is perfectly fine. Fast forward a year. You're into November of 2022, and the history is different. All of a sudden now, we fell off a ladder after bricks hit us and we did lose consciousness. That is a significant deviation between the initial emergency room visit. And not to mention there is an initial emergency room visit that provides a completely different history. So now he's saying that he in November of 2022, he's saying he's in difficulty concentrating and he is limited range of motion in the neck and back. Now, in November 10th of 2021, neck back arms were found to be full range of motion and pain, free and supple. What that means is, is that the person was able to have full range of motion, which means that their neck could go all the way down to their chin and all the way back. That means that they were able to bend over to their toes and they were able to come all the way back and it was pain free. So when they made him do it, he didn't complain of pain. He didn't say there was any problems. A medical term that you need to learn is edema or erythema, which is basically swelling if there's no erythema, which is discoloration or edema, which is swelling, then and there's no tenderness. Tenderness in terms of a medical term means that a medical provider is going to poke the site with their finger, they're going to press on it, and if you say, oh, that's that kind of hurts, that's tenderness. Okay. It's a very subjective test. But the fact of the matter is that someone two months after the injury was pressing on it and there was no tenderness. That's significant. Okay. These are all the things that you're going to note for cross examination later. Now. Let's assume for the minute and change the facts. Let's say the initial emergency room visit was on the date of the accident in September. Okay. The examination of being full range of motion and. And no swelling, no tenderness. Plaintiff attorneys will always allege that that's due to shock and that, oh, hey, he felt fine because of shock and a drilling that's in his body. And, you know, he wasn't really processing it. And so if he ends up having soreness couple of weeks later, well, it's because he was in shock on the initial date. So that is something you also want to pay attention to. It doesn't detract from the fact that he was pain free at the time and he was able to communicate. But at the same time, you. Want to pay attention to the fact of, well, there might be issues later, but the fact of the matter in this instance, he didn't treat initially. He waited two months. And when he did show up, it was a different history and he was perfectly fine. So that is something that's very significant and something that you want to be using for cross examination. Okay. Now we're going to talk about breaking down medical reports. And we're going to start off by talking about the types of providers, because it's really important for you to understand what provider is treating the plaintiff, what are their qualifications, what are the limits of this qualifications, what is their expertise and how much oversight is there? So there are providers that require direct oversight. Those are physicians assistants, nurse practitioners, registered nurses and licensed practical nurses. One thing we want to keep in mind is that physicians assistants and it is quite, quite common nowadays for. An individual medical. Provider to do an initial evaluation and then turn over the remainder of the care to a physician's assistant who then examines, treats, diagnoses, the person or two, a nurse practitioner who examines and treats and diagnoses, and that the doctor will only come in and review the reports or check in and do like a six month check in. I in my personal practice, I found that physician assistants and nurse practitioners tend to operate independently with very little minimal oversight by the doctors. I've seen several cases where physicians, assistant nurse practitioners in order to try and resolve a patient's pain. They are overmedicating a person. They are over treating a person. So you need to really pay attention to who's really in charge and doing the treatment and making these recommendations. Is it a is it a medical doctor or is it a physician's assistant? And how much oversight? Now, registered nurses and licensed practical nurses have to actually have direct supervision. They're usually only in nursing homes and hospitals, etcetera. And they need to have direct supervision. So if they're going to do something, they have to be directly told by the doctor and there has to be a sign off by the doctor. So providers that usually require a doctor to prescribe treatment. So if you want to do physical therapy. Massage therapy. Or you want to go to acupuncturists, typically you're going to need a medical doctor to recommend or prescribe or give you a script for that treatment. You can see acupuncturists and chiropractors by themselves. But typically if you're if it's if it's in line with a claim, you definitely want there to be a script. Providers that can be limited in the types of treatments or the site they treat is a chiropractor in New York. They're limited to treat neck and back only. They cannot provide or treat causal relationship for shoulders, knees or things like that. But that's going to depend on your state and the type of litigation that you're in. You also, you understand that. There are different doctors for different injuries. And I do want to state that this is three most common doctors that you deal with when you're talking about personal injury cases. There are a host of other doctors, specialists, internal specialists, heart specialists. I mean, you think of a body part, there will be a specialist for it. So but this you just need to understand there's different doctors that do different things, okay? Like there's a specialty for urologist. So, I mean, now if you're doing an orthopedic, that means you can diagnose, treat conditions of bones, muscles and joints. If you're a neurologist, you're typically looking at spinal cord injuries, nerve issues. If you're talking about pain management, you're looking at managing pain. And usually it's chronic pain depending on the state. Chronic pain could be anywhere between over three months or greater than six months. So and the pain management could be looking at coordination of physical therapy, acupuncture, massage medications or injections. Typically you see a referral to pain management prior to surgery for them to undergo injections to see if injections help before they become a surgical candidate. That's usually when a pain management person gets involved. So there are different specialties for different doctors and you want to make sure that each doctor is staying inside their lane with their allowed to diagnose. You don't need an orthopedic doctor to come in and start talking about mental issues or depression because that's outside their expertise and they can't comment on it. There are different types of doctors for mental injuries. A psychologist and a psychiatrist. A psychologist is a PhD. They are not a medical doctor. They are the person that does talk therapy with anyone that's having mental distress or mood disorders or any type of mental distress. But they're not a doctor. They can't prescribe medications. We do see what psychologists do start trying to recommend people for medications. But really, if you're going to do medications, you have to go to a psychiatrist. And that's a medical doctor that specializes in mental health. And they can assess both the mental and physical aspects of your of the person. So and they can also prescribe medications. Now, when you're starting. With medical reports, the most important thing that I can say is that you never, ever, ever, ever, ever skip the basics. Because let's assume for a minute that you request medical. Records for Miguel Sanchez. What if there's ten Miguel Sanchez's? And what if you get. Provided the wrong one? So you need to. Check and it does happen. You need to check the name, the date of birth, the sex, the address. You need to make sure all of this corresponds with your claim. I can't tell you the number of times that, you know, you start getting into a medical record and you're like, Oh, this is great. This is a different history. This is completely different treatment. Like, we're going to tear this guy up on cross-examination and you forgot to check whether or not this is even your your, your your Miguel Sanchez. And 90% of the time it's not. So then you just have to get right and you have to let the the provider's office know that they've inadvertently disclosed something that's not related to the claim. And then you have to destroy those medical records. Okay. So make sure you've got the right person. All right? Happens all the. Time. So you want to. Focus on the history of the injury, the personal and family history. You want to look and see if they have diabetes, cancer, gout, anything that could increase or cause the issues that you're having. So, for example. If you have. Gout and a person is claiming bilateral carpal tunnel syndrome, gout causes that or aggravates that. So you need to know. Same thing with diabetes. It can also cause or aggravate. So maybe it's related to your claim, maybe it's not. You want to focus on current injuries? Prior injuries, the treatment that has been received or requested. And then also again, make sure you're paying attention to who is providing or coordinating treatment or care. I've seen cases where. A claimant. Is is is treating and no one is coordinating their care at all. And so it's all kind of like everyone's on these different paths and no one's talking to each other. So there's no plan to help the person ever get better. They're just endless treatment. While you're going through the medical. Reports, what are we looking for? Like, okay, so we're looking for factual inconsistencies. We're looking to make sure the treatment makes sense. We're looking for whether or not the injuries being alleged were actually injured and what. Treatment are they. Currently undergoing. But we're also looking at is there any improvement or lack of improvement from the treatment and how do you determine improvement? Well, we look at it in three ways. We look at it activities of daily living, and you will see it in medical reports listed as adls and subjective improvement and objective improvement. Those are the three things that we look at. Activities of daily living are activities that relate to personal care. It's bathing, showering, dressing. Driving, going to the grocery store by itself, cooking for yourself, all of those things. Okay. Can you function as an adult in the world on your own? Can you do those activities of daily living or do you need help with. Dressing. Cooking, cleaning? Those are the things that we're looking for. And maybe you start off being unable to do any of them. And then and then later after treatment, you can. That's an improvement. That's what we're looking for. Um. In terms of subjective improvement. Subjective means that it cannot be objectively measured by anybody. So if a person walks in saying, Hey, I've got pain in my shoulder and they do a bunch of tests and the shoulder is fine and the person is still complaining of pain, that's called subjective pain. We can't measure it, we can't quantify it, we can't objectify it. Um, and we have to rely on the person and what they feel. And that's what subjective is. Usually subjective pain is recorded by a visual analog scale called Vas, and it's usually 1 to 10. If you want to think about it, it's those happy faces that you see when the doctor troops out. When you're in there saying like, how do you feel today? And you say, Oh, and you point to a face and that will be 4 or. 5 out of. Ten, whatever it happens to be. Objective improvement is. Where we can actually. Clinically see that there is improvement in either your activities of daily living. A reduction in work restrictions or there is actual physical improvement from in your range of motion, or there's a reduction in your subjective improvement. So we're looking at so objective improvement is something that can be measured. So if here's a good example, if an individual comes in and he has a shoulder injury and he was only able to raise his shoulder to, you know, his shoulder and he's not able to raise it to his head well over the course of treatment, if he's able to raise it to his head and obtain full range of motion, that's improvement. Even if he's only able to get half way to his head. Well, that's an improvement from being limited to your shoulder height. So that's objective improvement. That's something that we can measure. We can measure range of motion, we can measure how much your improvement. So that's what objective means. Now. Here is where we're going to go. Into medical record. And we're going to do what? What I love we call is a common young associate mistake of diving into medical records without context and will tell you how hard it is, because when you do this without context, you're. Not analyzing. Medical records, you're just reading them. So let's start off with this is an actual medical report from one of my cases. Um, obviously I had to redact the important information, the sensitive information, but this is in November 7th of 2022, an individual comes in, he has bilateral hands, pain from vigorous, repetitive duties. For the past year, he had an MRI, an EMG study, which did not have significant findings. That's kind of interesting. He's already seen a rheumatologist. That's interesting. Kind of signifies that he may be older. Let's check his date of birth now. I did have to redact his date of birth, but his date of birth, he's in his early 20s, so the rheumatologist and the date of birth don't really match up because usually you'd see that in an older patient and he's already left employment and he's gotten different employment and he's working without restrictions at this time now. He had a prior cortisone injection, which did not offer any. Significant long term improvement. And you'll find that cortisone injections usually benefit. For 2 to 3 months. And if they don't benefit, that means. You may be a surgical candidate. If they do benefit, it means that you you. Can use. Conservative treatment like rest and relaxation to help them fix. Okay. So in the medical report, you can see how it says PMH. That means prior medical history and there is a problem list. So you are already talking about spraying of. A of. A ligament. You're looking at carpal tunnel. You're looking at tenosynovitis and a metacarpal joint. Now, if you've noticed. I've underlined a couple of things in purple. These are medical terms that you need to go to Google and look up and figure out what is the clavicle typical. Sorry, I can't even say it now. Clavicle ligament. What is it? What is the carpal metacarpal joint? Where is that on your hand? What is Tenosynovitis? Okay, go look up those things and increase your your bank of medical knowledge. And what I can tell you is that tenosynovitis simply means an inflammation of the joints that are swelling. Okay, so let's move on to medical problems. Your surgical history, nothing really relevant there. Anxiety is kind of a trigger for me because you just want to keep that in the back of your mind. And then you look at marital status, single, you're in your early 20s. That's kind of normal. But personal habits. First, he smokes on a regular basis and then he regularly uses marijuana and exercises sporadically. So if you're in your early 20s, the question really becomes exercise should automatically trigger a thought of what type of exercise is he doing? Because if he's doing deadlift weights that could really impact and cause severe strain on your wrists and that could be a reason for his complaints. The next that you look at is the height and the weight. And here's where height and weight is important. He's five five, so he's on the shorter side, but he's £100. So look at his BMI, 16.6, that is. Well, that's under weight. Okay. So that kind of indicates there may be he may have other issues as well. So his pain level is seven. So sometimes they'll the medical report will say Vas colon seven, but usually it just says pain level and seven or whatever the number happens to be. So then they give through the physical examination and it's really important that you go through the physical examination and understand it. The person's sitting comfortably. He's he was able to move without limitation. Finkelstein's maneuver was not overly positive. And there are. Two tests that. That. That that. Test for carpal tunnel syndrome. One of them is Finkelstein's you need to go look up. Finkelstein's. Maneuver. What does that do? What is the test Look like? Again, you're increasing your bank of knowledge. If the maneuver is not overly positive, that means his carpal tunnel syndrome may not exist anymore. If he did have it previously, you may have gone away, which is quite normal. Then you look at your. Mri and again. We're looking at. Proximal posterior lateral prominence. Go look up what that means. Cmc is your carpometacarpal joint and then tfcc is actually the ligament in your hand. If you're looking at your hand with your thumb on the left hand side, that is the ligament from your the bottom of your pinky down and it curves underneath your wrist. You want to go look that up, look at what it means and look for it. So you start increasing your your bank of medical knowledge. It's really important. It's also really important for you to understand how an. Injury occurred as well. So if someone says like. Oh, hey, I injured. Um. Like I'm having wrist pain and they're talking about ligaments in your fingers. Well, then that's two separate sites. That's two separate injuries. That's going to be a completely different analysis then if you're talking about your wrist. Now, here is something interesting is his five for 22 and EMG nerve conduction result. The previous said the. Mgs weren't weren't overly positive, but. They don't put the result in there. I find that when they don't put the result in there, it's usually negative, but it is listed. So go check your records. Is do you have that actual report? And not only do you have the report, do you have the actual films or the test itself? So in the MRI you're looking for. Do you write it down? Hey, you had MRI on this date. Do we have the films? Do we have the the MRI report? So the medical records are also you're going through to figure out, am I missing anything? Okay. So here is the impression the MRI. The MRI, they're. Usually just a cut and paste from an MRI. What you have to understand about an MRI is it's rarely interpreted by the treating provider. It's interpreted by a radiologist. If the findings are inconclusive, the provider will then go make his own determination by procuring the films. But usually the provider never looks at the films. They go based off of what the radiologist says. But you want to make sure what's in the report. Is actually in the the report, because. Sometimes it's. Not sometimes they copy the wrong thing or they leave stuff off. So at the end of the report, it says it's. Difficult based on the findings of this MRI scan EMG, to attribute his vague clinical points to anything specific that would warrant a hand surgery. So they're basically saying like, hey, he's having complaints, but honestly, there's nothing here to warrant us opening him up to try and fix his carpal tunnel syndrome. He really just needs to do conservative therapy and resolve it over time. Now, the next thing you need to understand is that they're utilizing a voice recognition software. And that is going to help them with. So that means that. There are going to be typos and they're able to correct those typos later, but they have to list that. Okay. Is the patient working? What is the percentage of temporary impairment? That will depend on the state of whether or not, if you're doing worker's compensation, whether or not that needs to be filled out. But most importantly, when you get to the end of the medical record, who is it signed by? If you notice, it's signed by a physician's assistant pas ce, and it's done in the supervision of the MD. The question is, did the MD. Come in and look at. The patient, or is it all done by the physician assistant? So all of that is really good information for you to know. So now you've read, you've done the Rookie Mistake, you've read a medical report, you haven't analyzed it because context matters. So let's look at scenario one and let's say the injured worker was hired one week to be data entry. Okay. Well, the medical report previously showed and we'll go back and look at it. Um, that he has been experiencing ongoing pain for a year. That's significant. So now what you've done is you're not being efficient. If you don't understand the context, you have to go back to the medical record once you know the facts and then pull out the significant findings. Now you're analyzing the medical records, so you don't necessarily want to start analyzing medical records without having that context first. So you already know that if he's only been working for one week, he's had pain for approximately one year. From a worker's compensation perspective, is this injury really related to his data entry for one for one week? Unlikely is his, you know, duties for that one week vigorous and repetitive? Probably not, because usually the first week is training and you're learning the systems. So I doubt that you're doing hard data entry for, you know, ten hours, 12 hours a day. But also one week is not sufficient time for you to develop carpal tunnel now. And he's already had it for one year. So now you want to know what was his prior job? What was his prior treatment? You want to list of providers, you want to go after all this. And this is the stuff that you're now you're analyzing the medical records. Okay. Now let's look at scenario two. The injured worker was hired for five. Years working as data entry. He's 25 years old. He's active on social media and he runs a YouTube channel on gaming now. Okay. Hired for five years. All right. Well, the history makes sense. He's been having pain for a year. That's fine. He does data entry. We're going to need a little more information of how many hours he's been done and what type of data entry it is. Um, and then whether or not he's required to work eight hours of the day or does he get breaks? Does he work for an hour and get a break? Does what sort of ergonomic conditions is he working in? Does he have a broken up keyboard? These are the questions you want to be asking. Now, the other question is, is he's active on social media and he's a gamer. Okay. So that means if you have an active social media history and you run a YouTube channel, that means you're doing a lot of gaming, which also can lead to carpal tunnel and cause these problems. So now you're going to go want to. Ask what's your social media. Handle? Obtain all of the YouTube channel videos that are out there. You want to build a picture that. It's not your. Injury because of the other things that he was doing or there's other contributing factors. So those are the questions that you should be asking. So when you're looking at it, you can then go back and see. Then you're analyzing the medical records because. Then you're saying, okay, prior history has anxiety, he's under weight. And that's you analyze the medical records in the context of the injury. Okay. Now, in this one, we're looking at case study. Who is Bob? And we are looking at a construction worker that falls off a scaffold, two stories down. And this was a case that actually was part of. And he was injured on August 10th of 2022. He ended up having a right knee surgery immediately thereafter. In a deposition, he basically advised that he was completely unconscious. He was picked up by two workers, carried through floor, carried down three flights of stairs. He was carried to a car and ambulance wasn't called. And the supervisor drove him to the ambulance, to the hospital, and he was drug out by the supervisor, left at the front door. Of the. Hospital. And and and the supervisor disappeared. The employer, however, has a. Radically different history. The employer was like, Yeah, he complained that he had right knee pain. He complained that he bent down. He stood up and had right knee pain. He was. I had him take off his trousers. I inspected the knee, which is another issue we won't get into. But and there was no red marks. There was no swelling. There was no issues. I asked him if he wanted to go to the hospital. He said yes. I drove to the hospital. He walked in on his own. I hung around in the parking lot waiting for him for two hours to come out. He came out. I drove him home. That is it, sir. That's two completely different things. Now, what is. Understood and what is conceded that he had right knee surgery shortly thereafter. So let's go look at his medical records and see now that we have context. Now we have. And literally on a legal pad. What I would want you to do is bullet point out consistent, inconsistent. What are the questions that you have? And then you want to do a deep dive into the medical. Okay. So. Vital signs. His height, weight. We're checking his name. We're checking his date of birth. We're checking his address. We're making sure that it's our person. Okay, Let's assume we did that. The second thing that we're going to do is we're going to look at his height and his weight. So his BMI is perfectly normal. Height is 68in, weight is 150. So you're perfectly fine. You're not. Overly. Obese. That would cause knee issues. And then you're looking at it and say the date of service is seven 2722. Well, that's prior to my injury, right? The body part is the right knee. Interesting. And then all of a sudden we've got a right ACL from a motor vehicle accident last June. Has nothing to do with the scaffolding fall, a right knee, partial thickness tear and a right knee, um, motor vehicle accident. All right. So right now, none of this. Is quite making sense because the medical report is dealing with something that. Is prior. To our injury. Okay. But it does indicate that his failure to disclose this prior injury is a problem. So now we already know that he already had tears, he already had a problem. And whether or not he had. Did he have a surgery? Then it gets down to where another medical report indicates. That he's. Microdosing in mushrooms. He's violating. He hasn't told his parole officer. He abstains from alcohol and he. Would. Like to volunteer at a local. Food bank. He would like to start drawing mazes because. It was a longtime hobby of his. So none of this is starting. To make sense. You're seeing that. Okay, now he's treating with someone and now he's talking about that he's microdosing mushrooms without consent or a provider knowing about it or talking about it or overseeing it. He is not doing this under the supervision of a health care provider or a microdosing specialist. He's only doing his own research. And then you have the other issues where, okay, now we know he violated his probation. Okay. Well, he was in jail at something for something. Now we have to go find out what he absence for alcohol. That means he has a substance abuse problem and that his And that may be relevant to our claim. Okay. So the action items off of those medical reports start. Off straight. Up by saying we need a subpoena, medical records for the providers that have been identified. Reach out to opposing counsel to secure those additional releases. Subpoena his criminal history. It may be relevant and may not be, but request them try to get them subpoena treatment records related to alcohol abuse and mental health treatment. If you didn't have a mental health release. Now you can go get. One because you have a mention of a medical report of something that may be relevant to your claim because he's microdosing. And then you're going to review emergency. Room records to determine whether there's any drug seeking behavior. Because if he has a substance abuse problems, it is not uncommon for a person to then start inventing issues, slamming your hand in a car door in order to go get opiates or pain medication. If you start seeing opiates or pain medication being prescribed, that could be an issue. So and then you also want to address with the employer whether the plaintiff was exhibiting odd or manic or interesting behavior on the day of the accident. Now, for this. Particular instance, we also have a medical report that comes through and later talks about the date of the injury. And for this particular case, it turned out that. For the medical report that was provided on August 10th was the claimant. Walked into the emergency room. He complained that he had right knee pain. He had the person. Evaluated and found that he had an issue with his right knee. He may need surgery and he was recommended for surgery right then and there. And then he ended up having it, you know, a couple weeks later after an orthopedist agreed that he does need the surgery. But fast forward three months. His medical. Records for the next year talked about this allegation of falling off a scaffold for two stories and where he's having all these issues. So when during our deposition, he alleged that the different history was because the hospital didn't have a Spanish translator. And what we were able to pull out from the initial medical reports is that not only was the Spanish translator there, but they were identified and that he consented to several procedures. He was able to give the history and all that is contained in the medical report, which we can that we then utilize to get the case just limited to the right knee. So it was accepted for the right knee. We just weren't accepting the story of falling down a scaffold and that is huge because that got rid of head, neck, back ribs, arms, legs, ankles and feet. And he was limited to a claim for the right surgery. So medical reports can give you not only a. Factual. Help, but it also can tell you like this, where it's telling you all the pre-existing issues. The fact that now we can go seek apportionment to a prior right knee ACL tear and we can look at whether or not it's the same ACL tear as previously, we can compare MRIs. We need to go get those prior MRI reports. We need to compare the MRIs to see if it's a different tear. To a different ligament, or are we just. Constantly re tearing the same ligament over and over again? And will he need eventually a total knee replacement based off of if he if you're continually ripping the same ligament over and over again. But the medical reports will. Also give you information that tells you that you need to go find more information like probation, substance abuse. These are all basically with your detective hats on. You're putting together a picture, a jigsaw, and a good way to explain it is you are looking at a snapshot. Of a person. On the date of the injury and you want to do a snapshot before you want to do a snapshot. The date of the injury and then a snapshot six months later, then a year later. And what is the progression of the claim? And you will find. That over time. Most plaintiffs tend to. Slowly but surely exaggerate their claim. I find that most plaintiffs that were legitimately injured the claim for the first year or is fairly cut and dry, very consistent after that year. Again, most people are poor historians and your memory starts being affected. And I find out that after a year the. The. Injury changes, it becomes much more impactful for him. It becomes much more it's bigger somehow. And so you can start noticing inconsistencies as time progresses. And keep in mind, a worker's compensation claim is usually made within 30 to 60 days of the initial injury. Right. For general litigation, it may be two years for a claim claims even made. It may be 4 or 5 years before it even gets to the stage where you do depositions. So it's a much longer time frame. So in a worker's compensation injury, you are looking at affecting current treatment, whereas in maybe a general litigation you can't really affect current treatment. It's already in the past. So that all is going to play into the value of your claim. Okay, Now I. Can't stress this enough that you've got to familiarize yourself with medical terminology. You need to understand the major ligament groups, the muscle groups. It doesn't really do any good to go by anatomy book and learn to be a doctor. That doesn't help you. As you're going through cases, you're going to start developing a bank of medical jargon. But where I find that young associates don't do or. Fail at or have difficulties with. Is a better way of saying it is where they don't look up the medical terminology that's in the report and understand how that ligament is affecting your claim. That's where they don't do it. They just kind of skip over the medical jargon and you don't realize that the medical jargon is important. So, for example, you need to understand that there's differences between grades of ligament injury where you can have a medial meniscus tear in your knee, right. Which is a partial tear of a ligament to a complete rupture. That means the ligament is no. Longer. Attached to there, just floating by itself. Okay. You can have. A partial tear or you can have a complete rupture of an. Acl. Okay. You also need to understand that when a person says. Proximal and distance, they are distances from a standard point of reference. So if you're looking at it from a. If you're talking about an elbow injury, right? Your proximal is going to be the one that's closest to your body or closest to the elbow. The distal is going to be the furthest one away. That's what you're looking at. So if you're evaluating an elbow injury, when you say proximal and distance, your your proximal is gonna be the closest to the elbow, distal is going to be the furthest away. Okay. Medial and lateral is going to be inside versus outside. And you may think. Like, oh, that's not that important. It is a significant difference when you're talking about a medial meniscus injury in your knee versus a lateral. Meniscus. Those are two separate ligaments, two separate injuries, two separate problems. And so it's really going to be important for you to be able to distinguish between the two. Again, interior means you're the front. Posterior means the back. And then there's head injuries, concussions versus post-concussion syndrome. And of course, you have psychological diagnoses, mood disorder versus acute. And then. And versus PTSD. Those are different diagnoses. They have different treatment recommendations. They have different. Codes. They have different recommendations in the DSM. All of these things you need to go look at. How does it pertain to your claim and try to make sense of it and how does it pertain to. Does this make sense? I've been down on my right knee. I came back up. I have a tear in my medial meniscus. Is that possible? Yes. However, if you're. 20. And you. Bend down. Mm. Put your knee on the ground and then you come. Up and you have a complete tear of your ACL. Is that. Reasonable? No, because a complete rupture of an ACL for a young person will require significant trauma and you bending down on your knee on the ground is not a significant trauma. It's a non event. So if you did tear your ACL, that means it was previously torn and you need to go find those medical records. Okay. Now, the other thing that. You want to pay attention to is medications. You have over-the-counter medications that synephrine ibuprofen bandages, Voltaren gel, icyhot diclofenac gel. And if you want to know the difference in gel and Voltaren gel, absolutely nothing. It's the same thing. One just has a greater strength and its brand name. So the other thing that you look at is prescription medications. Okay, you're going to want to look at branding versus generic. And how. Do you tell something is brand name versus a generic? Basically the name Percocet is oxycodone paracetamol, right? Now or acetaminophen. Now. Percocet. You could say it's kind of difficult to say. Oxycodone, paracetamol. It's not the greatest. Okay. Vicodin, It's hydrocodone. So the brand name is Vicodin. Very easy to say. Hydrocodone. Not so easy to say. Hydromorphone is the generic name for Dilaudid. Dilaudid is easy to say. So really, if you're able to say it, usually that's a brand new medication. Generics are usually quite long, and it's the medical terminology. And now the best practice for. Opioid medications have radically changed since the opioid epidemic. And you should be seeing acute. Injuries for less than a seven day script. If you're seeing more than that, you should be thinking, is there drug seeking behavior? Is there any issues? How severe is this injury that it warrants, A 30 day strip of medications? What is the ongoing treatment? Is he going to be having surgery soon? Like there are things that you should be thinking about and questions you should be asking in terms of chronic use of prescription medications. It's not recommended by the CDC, but it does still happen. But the CDC recommends that it's less than a 50 morphine equivalency dose daily. Again, look up what morphine equivalency dosage means. It means how much morphine a day you take, and it will be different between hydromorphone and Percocet. There are various levels and. Allows you to compare. Different medications and different opiate strengths. But since they contain different by linking everything to morphine. So the Med allows you to compare different medications by linking it to how much morphine is a person getting in a day. And so the CDC is recommending that, hey, if you've got less than 50 more frequency dosages per day, that's okay for chronic to treat chronic pain. But there needs to be pill counts. You need to be checking to make sure the person's using the pill counts and not stockpiling medication, that there's urine screens that they're actually taking the dosages and you can tell and that there's a rotation of medication. So all that needs to be in there. And if it's not. Then that's a problem. And that means that maybe. There's not enough oversight. Maybe the person is just going for endless treatment to build up their case. Maybe there's a relationship between the provider and the plaintiff's attorney that we're unaware of yet, so you need to just pay attention to things. Other medication related treatments that are popping up in are new cannabis. While it remains illegal at the federal level there, you. Need to recognize that. It could be legal in your state and. There will be, but there will always. Be. Even if. It's legal in. California, Colorado, New York. There is a difference between adult use, which is recreational use and medicinal use, which is medical. So if in cannabis you are taking cannabis. For a medical purpose, you're going to need a medical prescription card, You're going. To comply with state requirements, recreational uses, probably you just self dosing and it's. Not under the. Supervision of a physician. Then you have injections that are usually done by a pain management doctor and that is steroids and ketamine and. You're going to need to understand the relationship between an injection and how. It's supposed to. Impact. So, for example, if you inject a steroid into your shoulder injury and it significantly reduces and increases your range of. Motion, you may not be a surgical. Candidate for a. Shoulder. Replacement, but if the injection does absolutely nothing, there's a possibility that that you may need to have surgery in order to repair your shoulder. It just depends on the nature of the individual and their response to the injections. You're looking for that subjective and objective improvement. Okay. So these are the treatments that we're looking at. We're looking at whether the treatment started or increased after our injury. Are there any preexisting injuries, prior substance abuse? You know what? Treatments are really working for the plaintiff. We're looking for that subjective and objective improvement. And we're looking for really the objective function of what is there, uh, what treatment is worked, what treatment is related to this injury? What is preexisting and. Not. Related to my injury at all? You need to start separating it out. And the reason you're doing that is because it has a direct impact on the value of your claim. Now, if you're a plaintiff's attorney, you're going to go broad, you're going to try to loop in everything and you're going to say, hey, yeah, pre-existing knee issues. But they've been aggravated by this injury. So previously he wasn't a surgical candidate. Now he is a surgical candidate. That's your argument as a plaintiff on the defense side, You're going. To argue that if he had preexisting knee problems and was recommended for his surgery before and he did not undergo it. Then my. Injury didn't change his knee issues. He still needed a surgery. Now he just wants me to pay for it. So there are the two separate things. You want to always look at. It from. A context of what the medical records are doing or tell you about your claim. Because again, we're not just reading medical reports, we're analyzing them. We're looking for the patterns. We're looking to see how it affects our litigation. Okay. So that's kind of the end of it. Wants you to understand that. You have to understand, know your claim, know how to get the medical records and review the medical history with the claim in mind because context matters. Okay. You want to. Understand the nature of the injured parties injury, but you also want to sit there. And go through the medical. Records with a fine tooth comb, pointing out inconsistencies and factually inconsistencies in the medical treatment. If he's saying that he had no prior injuries to his knee and you're. Seeing medical reference like an. Mri report. That was compared to another MRI report that predated. Your injury? Well, then that kind of implies there's other medical reports out there that we should be going after. Okay. And then you want to look at red flags, which may or may not be relevant to the. Claim, depending on what what context you're in. But substance abuse, alcohol, undisclosed prior treatment, arrest records, these are red flags in addition to the factual inconsistencies that you want to pay attention to and highlight and see if there's investigation that needs to be ongoing. Again, you are building a picture on the overall timeline. You're taking a snapshot of them before snapshot of them at the time of their injury and afterwards and seeing about whether this is a legitimate claim, what actually belongs in the claim and how much evaluation does it depend on the claim? Okay. If you have any questions, please feel to reach out to me again. You can reach. Me at misunderstood lawyer at gmail.com or at social media at the misunderstood lawyer. Thank you for your time today and best of luck.