Common Problems With Medical Records in Disability Cases

by Sydney Brown | February 1st, 2017

The Social Security Administration (SSA) requires you to prove, primarily through medical records, that you are disabled. This sounds simple enough at first glance, but have you ever actually seen your medical records? Odds are, your medical records contain many, if not all, of the common problems we see in disability cases. The good news is that you can take steps to help prevent these problems from continuing to appear in your medical records. Although there are many potential problems, this article will focus on the most common areas of concern: 1) complaints and side effects, 2) physical examinations, and 3) doctor recommendations.

Medical records are broken down into distinct sections. The first section is for subjective complaints, meaning the reason you are at the doctor’s office and the problems you are having. The second section is for objective observations. This is the portion of the record that contains the doctor’s physical examination notes. The third section is for any diagnoses for your medical condition(s). And finally, the fourth section is for the doctor’s plan of action. This is where your doctor will document if they are sending you to a specialist, if they are prescribing new medications, or if they want to send you out for further testing.

Problems With Complaints and Side Effects

The subjective complaint section of your medical records is crucial. SSA will look here, first. What do they look for? In short, everything. SSA wants to see what you are telling your doctor about your own symptoms and side effects. Did you come into the office with back pain because you injured yourself moving furniture, or did you simply twist the wrong way and it caused excruciating pain? Do your medications make you sleepy? Dizzy? Nauseous? Did the injection or surgery you had improve your pain?

The biggest problem here is that when you are disabled, you have to go to the doctor frequently. Frequent doctor’s visits lead to you just wanting to get the visit over with and get back home. So what do you say when the nurse or doctor asks why you’re there? “I’m here for my medication refills,” or “I’m here for my follow up.” You give quick, short answers to your doctor that yes, your medication is helping you. Even if it isn’t. And so, your medical records reflect those answers and that’s it.

When this happens, SSA holds that against you. SSA frequently cites to a claimant’s own statements to their doctor to help justify denying their case. For example, if you say you’re at the visit for “medication refills,” SSA says that your medication must be controlling and relieving your conditions because you aren’t complaining of pain or continued symptoms. If you never mention your medication side effects to your doctor, SSA uses your medical records to prove that you don’t actually experience side effects to the level you explain to them. So, how do you fix this?

Open up to your doctor or nurse at every appointment. Always say exactly what is happening with your mind or body, talk about the side effects from your medications, and rate your pain, symptoms, or improvement on a scale of 1-to-10. If you feel like you are repeating yourself every time you see the doctor, then you are probably doing an excellent job at fixing this common problem in medical records!

Physical Examinations

Physical examinations, or the objective observations of your doctor, are an equally crucial section of your medical records. SSA looks here to see whether your doctor physically sees that you have problems standing, squatting, bending, walking, gripping, getting on or off of the examination table, etc. The biggest problem here is that in many office visits, you’re already sitting when the doctor comes into the exam room. Then your doctor sits down and talks to you but doesn’t actually watch you walk, see you bend over, look at your spasming muscle, or even put their hands on you.

When your doctor doesn’t do these things, often times your medical records still reflect that he or she examined you. That’s right. And why is this a problem? Because odds are, that documented physical examination that never really happened likely says that everything looked normal. Walking? Normal. Bending? Normal. Strength? Normal. Breathing? Normal. When examinations appear normal in your records, SSA uses them to prove that your reports of pain or limitations are not as bad as you are reporting.

This is, thankfully, the easiest fix of them all. Be an advocate for yourself and make your doctor examine the things that you know are wrong. If you can’t bend over very far because of your back pain, show your doctor. If you walk with a limp, show your doctor. If you have swelling, show your doctor. And do this every time you get medical treatment, even if you’ve shown your doctor the very same things before.

Doctor Recommendations

Doctors don’t always write down what they tell you. Your doctor may tell you not to do certain activities, such as lifting above ten pounds. Or, the doctor tells you to go out and get a cane to help you walk. They might even tell you that they think you are disabled and should apply for disability. If your doctor does not write these things down, SSA says that it must not have happened.

Simply get your doctor to give you that information in writing for your own records. Then, give a copy of that record to your disability lawyer.

As you can see there are many factors that go into proving a disability with the SSA. Call Rainwater, Holt & Sexton to speak with an attorney and get help with your claim.

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