What a file from this office contains: 8 documents, 1 PDF, 1 signature.

Medical documentation for a personal injury case is the written record that connects the mechanism of a crash to objective findings, the findings to treatment, and the treatment to the client's response over time. At Car Accident Doctors Group that record is produced by Dr. Carol McNamara-Krauss, DC, from the first examination to discharge, and kept in a proprietary case documentation system built in consultation with personal injury attorneys.

The file, in order

#	Document	When	Contents
1	Intake and crash history	First visit	Date of loss, mechanism of injury, seat position, restraint and airbag use, symptoms and onset, prior history, carrier and counsel information
2	Initial examination report	First visit	Orthopedic and neurological tests with results, range-of-motion measurements, palpation findings, diagnosis, treatment plan, work status
3	Imaging referral and report	When indicated	X-ray or MRI referral with clinical rationale; the imaging report filed on return
4	EMC referral	When warranted	Referral to an MD, DO, PA or APRN for the emergency medical condition determination, with the outcome filed
5	Visit notes	Every encounter	Status, regions examined, treatments rendered and where, response, plan
6	Re-examinations	At intervals	Updated measurements and findings against the initial baseline
7	Narrative report	On request	Prose summary: history, objective findings, diagnosis, treatment, response, prognosis, referrals
8	Discharge summary	End of care	Final status, residuals, recommendations

How records are requested and delivered

Requests go to Janelle Deal with the client's signed authorization. Records are compiled from the documentation system and sent as one PDF. She is also the contact for status updates during care, so a paralegal preparing a demand letter has one number to call.

Why the treatments are named in every note

Each visit note records which modality was applied to which region: adjustment, Antalgic-Trac decompression, LightForce Class IV laser, Chattanooga shockwave (extremities and soft tissue only), therapeutic ultrasound, electrical stimulation, massage therapy by Dawn Marie Teufel, LMT, or nutritional counseling. Because treatment is chosen from findings rather than applied as a package, the notes show the plan changing as the client's presentation changes, which is what a reviewer expects to see in a legitimate course of care.

What the records do not do

They do not contain an emergency medical condition determination, because this office does not make one. They do not offer opinions outside chiropractic scope. They record what was found, done and referred. That restraint is what makes the rest of the file credible.