The plaintiff's mother testified that she was with her at the emergency center, where she first heard that the plaintiff had ridden a motorcycle with the defendant a week earlier, when during the ride she felt a very strong blow to the tailbone. Regarding the registration in the medical records, the mother testified [Prov. lines 1-7 at p. 67]:
"A: She said, I know I know this document, she said there was the story that I just told you, and she thought it might have something to do with the occasional massage she didn't hide anything.
Q: So she didn't think it had anything to do with the accident?
A: Absolutely not, she said it as part of
Q: As part of that, and the doctor chose to prescribe only that.
A: Probably."
A perusal of the medical documentation document dated April 27, 2018 shows that this is laconic documentation, which does not include a record of an accident or riding a motorcycle, and all it states is that the plaintiff suffers from pain "after a massage". It was also noted that the clinical examination was normal, and that the intensity of the pain was level 10, and accordingly the plaintiff received treatment with injections. It should be noted that the documentation is inaccurate in that it states that the plaintiff suffers from pain in her upper back, but she was referred for a lumbar spine X-ray, and the diagnosis reads: "LOW BACK PAIN" [pp. 120-122 of the plaintiff's exhibits].
- However, according to the case law, it is important to have preliminary medical documentation, which is perceived as an authentic description of the circumstances of the incident. At the same time, it is necessary to examine the circumstances in each case, and in particular the nature and intensity of the injury, the ability of the injured party to maintain the record, as well as his awareness of the importance of accurate documentation of the circumstances of the accident in real time. The plaintiff arrived at the emergency center suffering from severe pain, as also recorded in the medical records, and I am of the opinion that in these circumstances it is difficult to demand that she be careful about the details of the record, and that she verify the registration of the details of the event that are not relevant to the medical treatment.
The existence of a missing or inaccurate medical record is not at all uncommon, as discussed in the case law, when it was held that "a medical record is not the be-all and end-all, and it can be said that there is judicial knowledge that sometimes not everything that is said during a visit to a doctor is actually recorded in the medical document, and the parties are not always aware of the importance of the registration at that moment and do not even feel comfortable asking the doctor to amend the record." (T.A. (Krayot) 51776-03-11 Bahar v. Shomra Insurance Company in a Tax Appeal [published in Nevo] (December 13, 2014); see also T.A. 70321-10-18 A v. Givatayim Municipality [published in Nevo] (December 16, 2021); T.A. 25717-08-10 Shibli v. Clal Insurance Company in a Tax Appeal [published in Nevo] (June 28, 2014); T.A. (Shalom Hai) 18524-06-19 Anonymous v. Harel Insurance Company in Tax Appeal [Published in Nevo] (February 3, 2022); T.A. (Shalom Teb. 9748-04-19 Anonymous v. Phoenix Insurance Company in a Tax Appeal [published in Nevo] (February 28, 2022); T.A. (Tel Aviv) 47679-10-12 Masarwa v. Hachsharat HaYishuv Insurance Company in Tax Appeal [published in Nevo] (June 17, 2015)).
- In view of the circumstances in which the plaintiff came for medical treatment, I am of the opinion that it is possible to accept her version regarding the lack of medical documentation, which also includes erroneous information, some of which is not in dispute. The plaintiff's testimony regarding the details she gave at the emergency center is not the only testimony, and it is supported by the testimony of her mother, who made a reliable impression, and testified that she first heard about the circumstances of the incident during the treatment. The plaintiff's version is also supported by the testimony of the neighbor, who testified that the plaintiff told him close to real time, the day after the incident, about the motorcycle ride and about the injury and the pain in his lower back. The neighbor's testimony was not contradicted and was reliable and consistent, and I believe that it should be given considerable weight.
Moreover, the plaintiff's testimony regarding the very existence of the travel event is also not a single testimony, since the defendant stated that there was a jump or vibration or trembling, and the dispute between the parties is regarding the intensity of the event and the question of the causal connection between it and the plaintiff's pain and its definition as a "road accident".