Your Records Tell the Story of Your Spinal Cord Injury

If you were hurt in a crash and think your spinal cord was injured, you may be wondering which of your papers could matter most as evidence. Your medical records show what happened to your body and when, and complete, dated entries make that timeline easier to follow.

For people in Albuquerque and across Bernalillo County, a spinal cord injury lawsuit can rest on imaging and notes made in the first days after a crash. This guide explains which records matter, why early imaging counts, and what to do now.

What the Medical Record Does in a Spinal Cord Injury Claim

The medical record is the main way a spinal cord injury’s cause, location, and severity get written down over time. Doctors, nurses, and therapists record what they see, test, and treat at each stage.

Memory fades, and symptoms change. A note written on the day of a visit carries more weight than a recollection months later. The record should match the accident and the symptoms you report, no more and no less.

Consistency matters as much as detail. When the same symptom shows up in the emergency notes, the exam, and the therapy notes, the story holds together across providers.

Causation is the link between the crash and the injury. Under Herrera v. Quality Pontiac, a proximate cause is one that, in a natural and continuous sequence, produces the injury and without which the injury would not have occurred. It need not be the only cause or the nearest one. Your records are how that link gets shown. New Mexico’s uniform jury instruction on causation puts it this way: an act is a cause if it contributes to bringing about the injury and the injury would not have occurred without it.

Which Records Matter Most, and Why

The most useful records are the ones made close to the accident and at each change in your care. Ask for these from every provider.

• Emergency department notes. These show arrival time, how you described the crash, your first neurological findings, and which scans were ordered.
• Imaging reports. MRI and CT reports include the radiologist’s written findings and the date each study was done. Keep the written report and any images.
• Neurological exam notes. These record strength, feeling, reflexes, and changes in movement at each visit.
• Therapy and follow-up notes. Physical and occupational therapy notes, rehab records, and physician visit notes show symptoms and limits over time.

Each record adds one piece of the timeline. Together they show what happened on the day of the crash and how your symptoms changed in the weeks and months that followed. Ask each office how it releases records, and follow its steps. Read each record when you get it. Small errors, like the wrong side of the body, are easier to fix early.

Why Early Imaging Carries Weight

Early imaging creates a dated, objective record of what was visible shortly after the accident. That timing is why first-day results often matter to a claim. A scan done when symptoms first appear is tied to the accident in time, which makes that link easier to follow.

MedlinePlus describes the diagnostic tests used to evaluate spinal cord injury, and imaging is part of that workup. Imaging alone does not finish the picture. Doctors read results alongside the exam, so the notes that tie a scan to your symptoms matter as much as the images.

If your first imaging was done in an emergency department, ask for the written report, even if a doctor summarized it for you. The report is the source document. If you had imaging more than once, keep each report, because the comparison between them tells part of the story.

It still shows why a normal first scan is only one part of the record. Report every symptom at each visit, even when a first scan looks normal.

The Treatment Gap Problem Insurers Look For

A treatment gap is a stretch with no documented care after the accident, or between visits your provider prescribed. An insurer may point to a gap and argue that symptoms were not serious or came from something else.

That argument turns on causation. A gap is a fact the other side can raise, so it helps to have the reason for it in the record. Maybe you could not get a ride, or a visit was rescheduled. Say so at the next visit, and ask that the provider note it.

Gaps are read in context. A short wait for a referral reads differently than months with no visits at all. Keep a dated note of why you missed or delayed care, such as work shifts or transportation problems. A note written at the time is more useful than a memory later.

When care is delayed for any reason, tell the treating provider about every symptom at the next visit. Describe even minor symptoms, because the provider can only record what you report.

Keeping Your Records and Requesting Copies

Keep every appointment, and request copies of your records from each provider in writing.

• Attend appointments and therapy sessions, and follow the treatment plan your provider sets.
• Keep a simple symptom log with dates, what you felt, and what you could not do.
• Keep discharge papers, prescriptions, imaging discs or printed reports, and bills or insurance statements tied to the injury.
• Write down the date you asked for each record and the date you received it.

If a provider’s office is slow, send a written reminder and note the date. A paper trail makes follow-up easier. Keep originals and copies in one folder, paper or digital, sorted by date.

For the crash itself, NMSA 1978, § 66-7-207 requires the driver of a vehicle involved in an accident with bodily injury or death, or total property damage of $500 or more, to send a written report to the department of transportation within five days. Keep a copy of anything you file or receive about the crash.

How El Gringo Law Reviews Records in a Claim

El Gringo Law reviews the records you already have to see what is documented and what may be missing. The firm handles spinal cord injury claims, along with car accident and other injury matters in New Mexico.

Josh Wood is the responsible lawyer for this page. He is licensed in New Mexico and Arizona. Emergency notes, imaging reports, exam notes, and therapy notes are among the records that document an injury.

Bring any notes you wrote about symptoms, dates, and daily limits to a review, along with the records above. A review can show what is documented and what still needs to be requested. Every case is different, and past results do not predict a similar outcome.

Talk With El Gringo Law About Your Records

If you’re in Albuquerque with a spinal cord injury from a crash and aren’t sure which records you still need, bring what you have to us. Our initial consultation is free, confidential, and carries no obligation to continue.

Reach out through our contact form, by chat on our website, or at elgringolaw.com. Josh Wood is the responsible lawyer for this page, and El Gringo Law is responsible for its content.

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