How to Document Medical Treatment After a Premises Accident

Why Medical Documentation Matters After a Rochester Premises Injury

Getting hurt on someone else’s property can turn your life upside down. You may leave the scene feeling sore, shaken, or unsure what to do next. But what happens in the hours and days after matters, a lot. Documenting your medical treatment isn’t just about getting better. It’s about protecting your rights if that injury wasn’t your fault.

At Horn Wright, LLP, we help people throughout Rochester and Monroe County who’ve been injured at stores, parking lots, apartment complexes, and other local properties. Our attorneys understand how to build strong, clear cases backed by detailed medical documentation. If you’ve suffered injuries in a slip and fall incident, our team can guide you through every step so you can focus on healing while we handle the rest.

Seek Immediate Medical Attention in Rochester or Monroe County

If you fell on icy steps or slipped on a wet floor in a Brighton plaza or downtown Rochester store, don’t wait to “see how it feels tomorrow.” Go to the hospital or urgent care the same day. Immediate treatment creates the first official link between your injury and the accident.

Carefully document where you went and when. In Rochester, that might mean visiting:

• Strong Memorial Hospital or Rochester General Hospital
• A nearby urgent care like WellNow or UR Medicine Immediate Care

Tell the provider what happened and ask that it be included in the record. Paramedics from NY State Emergency Medical Services (EMS) may also file a report if they respond to the scene. Keep any paperwork they give you. Even a simple discharge form matters.

Tell Your Doctor Exactly What Happened

Your own words play a big role in what gets written in your medical file. Be clear. Be specific. If you fell in the East Avenue Wegmans because there was water on the tile floor, say so. If your ankle rolled stepping off a curb at a property in Irondequoit, mention that too.

Make sure the written report matches what you said. If something feels off, politely ask for a correction. It helps to:

• Mention the exact location (including address if you know it)
• Describe your symptoms clearly: sharp pain, swelling, dizziness, etc.
• Clarify the timeline: when it happened and how long you’ve had pain

This initial conversation becomes a foundation for your entire medical record. If it’s vague or inconsistent, that can hurt both treatment and any future legal action.

Follow the Entire Treatment Plan Without Gaps

Once your care team lays out a plan, stick with it. Gaps in treatment make it seem like you weren’t that hurt, even if you were just overwhelmed or couldn’t get a ride.

In Rochester, many providers use online tools like MyChart to schedule follow-ups and view test results. Use these to stay organized. Don’t skip visits with:

• Orthopedic clinics at UR Medicine or Rochester Regional Health
• Physical therapists located near your home or work
• Specialists like neurologists if you had a head injury

If you need transportation help, keep receipts for Uber rides, RTS bus passes, or gas mileage. These all show that you kept taking care of your injury. You can also check the current federal rates for mileage reimbursements if you’re tracking personal vehicle travel for appointments.

Keep a Personal Injury Journal With Daily Symptoms

A doctor sees you once every week or two. But you live in your body every day. Keep a log that captures your pain, mobility, and emotional stress. This record offers a personal view that your chart alone might miss.

Use a paper notebook or digital tool, whichever works best for you. Write something every day, even just a few lines. You might include:

• What hurts and when (e.g., “lower back pain after walking two blocks on Monroe Ave”)
• Trouble with tasks like laundry, cooking, or lifting your kids
• Missed work shifts at the University of Rochester or Xerox due to pain

Some people find that trying to walk around Highland Park or shop at The Mall at Greece Ridge helps them notice limitations they didn’t realize they had. Note those too. These details paint a fuller picture.

Request and Review All Medical Records

Under New York law, you have the right to request your medical records. Don’t assume everything is correct. Read through them. Providers can make errors or leave things out.

Request records from every provider you saw in Rochester or Monroe County, including:

• Imaging centers like Borg & Ide Imaging or Radiology Associates of Rochester
• Urgent care, ERs, specialists, and primary care
• Any physical therapy notes or surgical follow-up reports

Ask for complete records, not just visit summaries. That includes SOAP notes, imaging results, and diagnostic assessments. Review them for accuracy and save both physical and digital copies.

Save Every Bill, Receipt, and Statement

Even small expenses can add up fast. Create a folder, physical or digital, and drop every medical-related item into it. Don’t toss receipts, even if your insurance paid the bulk.

Your file should include:

• Co-pay receipts from your doctor or urgent care
• Prescription costs from CVS or Wegmans Pharmacy
• Ride-hailing or gas mileage logs for getting to and from appointments
• Over-the-counter items like braces, ice packs, or bandages
• Any insurance statements showing denied or out-of-pocket amounts

If you were treated at Strong Memorial and then referred to outpatient care, those separate bills matter. Together, they prove how the injury affected your wallet.

Connect With a Local Attorney Familiar With Rochester Premises Cases

Medical records are powerful, but they don’t speak for themselves. A Rochester-based premises liability attorney understands how to interpret them, organize them, and present them in a way that supports your case.

An experienced local lawyer knows how to:

• Link treatment records with specific unsafe property conditions
• Work with providers at UR Medicine or local clinics to get full documentation
• Spot patterns in cases involving properties in Monroe County

They may also coordinate with medical experts to clarify the long-term effects of your injuries. And they understand what juries or insurers in this region expect to see in a claim.

Protect Your Health and Your Rights

If you were injured on someone else’s property in Rochester or Monroe County, take your treatment seriously and document everything. Accurate, detailed medical records help doctors treat you better. They can also shape the outcome of any legal action tied to your accident. From the moment you seek care to your final follow-up, every step counts. 

If you need support understanding how this fits into a personal injury case, Horn Wright, LLP, is here to help.