Keeping medical records and treatment notes to support your recovery and claim

By Chris Salmon | Updated: September 27, 2025

After a work accident, keeping clear and accurate medical records is one of the most important steps you can take. Medical evidence supports both your recovery and any compensation or benefit claims you may make.

Good record-keeping can make the claims process smoother and help ensure you receive the right treatment and financial support.

At a glance

You have the right to access your GP and hospital records under the Data Protection Act 2018 (Source: NHS guidance)
Keep copies of all GP, hospital, and specialist reports.
Record details of prescriptions, treatment plans, and rehabilitation progress.
Accurate notes strengthen compensation and benefit claims.
Well-organised records help doctors and solicitors understand your recovery journey.

Why medical records matter

Medical records show the extent of your injuries, the treatment you received, and how your condition has developed over time. Solicitors and insurers rely on this evidence to establish the link between your accident and your injury, known as causation. Without clear medical documentation, proving your case can be more difficult.

What to keep

GP and hospital notes: including consultation summaries, referral letters, and test results.
Specialist reports: for example, orthopaedic assessments, physiotherapy notes, or psychological evaluations.
Prescriptions and medication lists: showing what drugs you have been prescribed and why.
Treatment and rehabilitation plans: including physiotherapy exercises, occupational therapy reports, and progress updates.
Personal notes: a diary of your symptoms, pain levels, and how your injury affects your daily life.

How records support your compensation claim

When calculating compensation, your solicitor will use medical reports to show:

The severity of your injuries.
The impact on your ability to work and carry out normal activities.
The likelihood of ongoing symptoms or future complications.

This evidence is used alongside the Judicial College Guidelines for the Assessment of General Damages in Personal Injury Cases to determine the right level of compensation.

How records support benefit claims

If you apply for benefits such as Statutory Sick Pay or Personal Independence Payment, you will need medical evidence to show how your injury affects your ability to work and live independently. DWP assessors rely heavily on medical records when deciding entitlement.

Real-world example

A warehouse worker injured his back while lifting. He kept a diary of his daily pain levels and physiotherapy progress, alongside GP records. When applying for Employment and Support Allowance, the detailed notes helped demonstrate his limited mobility. This evidence also supported his compensation claim by showing that he was unable to return to heavy manual work.

Tips for keeping effective records

Task	Why it helps
Request copies of GP and hospital records	Ensures you have official documentation of diagnosis and treatment
Keep all prescriptions and receipts	Supports claims for special damages and expenses
Maintain a recovery diary	Shows day-to-day impact of the injury on your life
Store records in date order	Makes it easier for your solicitor and doctors to follow progress

https://www.workaccidentadvicecentre.com/recovery-rehabilitation/keeping-medical-records-treatment-notes-work-injury

External references

NHS Resolution: Advice for claimants - guidance on preparing a letter of claim including treatment details, clinician names, and dates, plus evidence for special damages like medical expenses.
Ministry of Justice: Civil Procedure Rules - outlines requirements for disclosure of documents, medical reports, and evidence in personal injury claims, including fixed costs for reports.
Oxford Reference: Bolam test - explains the legal standard for medical negligence based on responsible professional opinion, essential for assessing treatment records in injury claims.

About the author

Chris Salmon is a legal commentator and co-founder of Quittance Legal Services. He has written extensively about workplace accidents, employment rights and the claims process. Chris's work has been cited in national media and he regularly contributes practical guidance to help injured workers understand their options.

More about Chris and WAAC

Last reviewed September 2025 by Chris Salmon

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