CHECK YOUR MEDICAL RECORDS

When is the last time you read your medical file?  Most people check their credit score once in a while--perhaps because of frequent TV ads that remind us to know our FICO scores.  However, not one person in a thousand ever checks on what's in their medical records.

Let me admit that reading medical records is pretty boring business.  Also, your medical record isn't the easiest thing to get your hands on.  Still, you are entitled to see what is in your doctor's records concerning your illness, diagnosis and treatment.  And the contents will likely determine whether or not you can be approved for a Social Security disability claim.  Also, other important decisions, such as getting life insurance, may depend on what is in your medical record.  Is all the information accurate and complete?

Here are types of notations in medical records that have been problematic with disability claims.  I offer these as examples of what to look for if you review the contents of your records.

  • What is NOT there is important.  Did the doctor adequately describe the frequency, duration and severity of symptoms and how they limit your daily function?  Are all symptoms mentioned?  Are they given credibility?  Have things been omitted?
  • Does the record contain objective medical evidence for your diagnosis/diagnoses?  Objective evidence includes laboratory studies, X-rays, MRIs, CAT scans or other imaging, etc.
  • Does your record refer to tobacco use, alcohol use or abuse, drug addiction or abuse, etc.?  If so, are these references accurate?
  •  Are there "harmless" references that may be used to "prove that you are not disabled" when taken out of context?  A few examples below:
    • "Patient recently rode up to Maine with husband, who is a truck driver."
    • "Patient is helping a friend remodel his home.""
    •  "Patient would like to find a job but says no one will hire him."
    •  "Was observed selling prescription pain medicine in the pain clinic"
    • "Just got back from a cruise, was a no show on last appointment."
    • "Called, out of pain medicine again, needs early refill, doctor says no more RX."
    •  "Cautioned to stop smoking, respiration will improve if not smoking."
There are a thousand other items that are in (or omitted from) medical records that can hurt you in a disability or other insurance application.  And some of the items in your record may not be accurate.  For instance, "Helping a friend remodel his home," may simply mean, "Walks down the street to friend's house, sits and watches him work and offers advice."  But it didn't get recorded that way.

Disability decision makers are required to examine medical records carefully, which they do.  Any one of the notations above, which may seem trivial to the patient, can be used to make a case against the claimant's credibility.  It pays to know what is in your medical record.  It also pays to be careful what you say to your doctor and to be sure the doctor is clear on what you mean when you say it.  Never say, "I am looking for a job," when you really mean, "I need the money and wish I was able to work."



 
 

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