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How to Document Your Birth Injury Case for Legal Purposes

Mother and Baby

When dealing with a birth injury case, thorough documentation is critical for building a strong legal argument. Proper documentation can make the difference between a successful outcome and a prolonged battle. At Potter Law, LLC, LLC, we know how overwhelming this may be, so here is what we recommend when documenting your child's birth injury case: 

Collect Medical Records

The first step in documenting a birth injury case is to gather all relevant medical records. This includes prenatal records, delivery room records, and postnatal records. Ensure you obtain:

  • Mother's medical records: Include all prenatal visits, ultrasounds, and any treatments or complications during pregnancy.
  • Birth records: Document the delivery process, including labor notes, the type of delivery (natural or C-section), and any complications during birth.
  • Newborn's medical records: Include Apgar scores, neonatal intensive care unit (NICU) records if applicable, and any immediate post-birth treatments or interventions.

These records provide a detailed timeline and medical history that can be critical in proving negligence or malpractice.

Maintain a Detailed Journal

Keeping a detailed journal is essential for capturing day-to-day impacts and observations that may not be reflected in medical records. Document the following:

  • Daily care routines: Note any special care or medical treatments required.
  • Symptoms and behavior: Record any unusual symptoms, changes in behavior, or developmental delays.
  • Medical appointments: Document visits to doctors, specialists, and therapists, including dates, purposes, and outcomes of these visits.
  • Personal observations: Include your own observations and feelings about your child's progress and any difficulties encountered.

This journal can provide personal insights and additional evidence of the impact the injury has had on your child's life.

Photograph and Video Evidence

Visual documentation can be powerful in a birth injury case. Regularly take photographs and videos of your child to document their condition and any visible symptoms or disabilities. Ensure to:

  • Capture progression: Take regular photos and videos to show changes or lack of progress over time.
  • Include treatment sessions: Record therapy sessions and any special treatments or exercises your child undergoes.
  • Highlight impact: Show how the injury affects daily activities and quality of life.

These visual records can help convey the severity and impact of the injury to a jury or judge.

Compile a List of Witnesses

Identify and list potential witnesses who can support your case. Witnesses may include:

  • Medical professionals: Doctors, nurses, and therapists who have treated your child.
  • Family and friends: Individuals who have observed the child's condition and the family's struggles.
  • Educators and caregivers: Teachers or daycare providers who can attest to the child's developmental challenges.

Witnesses can provide testimony that corroborates your documentation and offers additional perspectives on the impact of the birth injury.

Preserve Correspondence

Keep copies of all correspondence related to your child's birth injury. This includes:

  • Emails and letters: Correspondence with medical providers, insurance companies, and specialists.
  • Insurance claims: Documents related to insurance claims and any denials or approvals of coverage.
  • Legal communications: Any communications with legal professionals regarding the case.

Organizing and preserving this correspondence can help establish a clear communication trail and demonstrate your efforts to seek resolution and support.

Secure Expert Opinions

Expert testimony is often crucial in birth injury cases. Secure opinions from:

  • Medical experts: Specialists who can provide insights into the standard of care and how it was breached.
  • Therapists and rehabilitation specialists: Experts who can speak to the long-term impact on the child's development and quality of life.
  • Expert opinions can lend credibility to your case and help quantify damages.

Organize and Review Documentation

Finally, systematically organize all documentation for easy access and review. Create a comprehensive file that includes:

Medical records: Categorized by type and date.
Journal entries: Chronologically ordered for clarity.
Visual evidence: Indexed and dated for reference.
Witness list: Contact information and relationship to the case.
Correspondence: Filed by date and type.
Expert reports: Clearly labeled and summarized.
Regularly review and update this file to ensure all information is current and complete.

By meticulously documenting your birth injury case, you create a solid foundation for legal action. Comprehensive and well-organized documentation not only supports your claims but also enhances your ability to secure a fair and just outcome for your child.

Contact Potter Law, LLC, LLC today to schedule a consultation!