Setting the (Medical) Record Straight

Setting the (Medical) Record Straight

An applicant for Social Security Disability Benefits is chained to his medical records like a sailor is to his ship. And, as a sailor must work to keep all aspects of a vessel “ship shape,” an applicant for Social Security Disability Benefits is due to take steps to make his medical records reflect his ailments and their severity as clearly as possible. Yet, I very often see claimants who, in spite of having rearranged every aspect of their lives ranging from where and how they sleep, the clothes they wear, the places they go, and even the friends and family they visit due to the impacts of their disabling conditions, continually tell their treating doctor that they are feeling “Ok,” or “Alright.” The Administrative Law Judge that reviews those records can and will use the claimant’s own statements to their doctor to conclude that there is an inconsistency between the medical records and the claimant’s testimony about the severity of their symptoms made during the hearing that decides the disability application, and deny the claim.

While patients cannot control what their physician writes in the medical records, they can, at least, accurately report their symptoms and the affects those symptoms have on their life. When talking to a physician, an applicant for disability benefits is in a much better position if they make sure that they told their doctor what activities are limited by the symptoms of the disabling condition(s), and the steps taken to lessen them. For instance, the most common response to a medical problem is to rest. Consider a very typical scenario, a person that has come down with a cold. Such a person usually has no problem stating that he rested because he was not feeling well. I, however, frequently encounter claimants for Social Security Disability Benefits that do not tell their doctor, who is trying to determine the extent of symptoms from which they suffer, that their symptoms force them to rest and wait for the symptoms to improve on a daily basis.

In addition to taking care to accurately report the totality of the symptoms present, an applicant for Social Security Disability Benefits can improve the clarity of the medical records (upon which the award of disability benefits depends) by asking the provider some basic questions about the clinical or examination findings and the reported symptoms. Just asking the doctor these questions greatly increases the likelihood that the doctor’s responses will be included in the medical records. Consider asking the doctor questions such as these:

  • What do you think is causing my problems?
  • Are my symptoms consistent with your findings?
  • What are the findings that are important to my symptoms?

Again, a claimant cannot control what the doctor actually documents, but just asking the questions dramatically increases the chances that the doctor’s responses will be included in the medical records. Medical evidence that contains clear answers to the questions listed above are much more supportive of the conclusion that a claimant is, indeed, disabled, and will fo far in helping the Soloway Law Firm build, and win, your Social Security Disability Benefit Claim.

The disability process is long, difficult, and punishing on its own. Claimants should not make it more so by reporting for over a year to their doctor that they felt “Ok,”or that they were “doing alright” when really they have left the workforce, struggle nightly to find sleep, and avoid outings with friends and family because of severe, disabling symptoms.

The facts in your case helps us win your claim, so please make the additional effort in telling your treating physician, whoever they may be, the whole truth, that your symptoms are frequent and severe. When these complaints appear in the medical records instead of your comment that you are “Okay” or “Alright,” the Administrative Law Judge is much more likely to find your testimony credible and support the conclusion that you are disabled from full time work. When that is the truth, you must say it not only to the Administrative Law Judge, but to your treating physicians and other providers at each medical visit as well. This is your best chance of your words making it into the records reviewed by the Administrative Law Judge at the formal hearing that you have waited more than a year to finally attend, so make it count!

Learn more about the author, attorney Ian MacLaren, here: