Medical Records Checklist

ARTICLE 3 OF 6

Create a running list of every provider who treats the injury, beginning with onboard or emergency care and continuing through specialists, therapy, surgery, and follow-up.

Collect or identify: emergency records, shipboard medical records, hospital records, physician notes, imaging reports and images, laboratory results, physical therapy, prescriptions, work-status notes, operative reports, and discharge instructions.

Track expenses: bills, copays, prescriptions, braces, medical equipment, mileage, parking, lodging, and travel required for treatment.

Keep a medication list showing the name, dosage, prescribing provider, and reason for each medication. Note significant side effects that affect work or daily activities.

Preserve work restrictions and disability notes. Those documents can be important in evaluating wage loss and whether the injured person can return to the same maritime work.

If records contain a significant factual mistake about how the accident occurred or what symptoms were reported, raise the issue with the provider through the appropriate medical-record process rather than altering a record yourself.