The Importance Of Your Medical Treatment Records
In Your Disability Case
This is the 4th article in a series designed to explain the Social Security and SSI disability application process and to provide helpful information to individuals applying for those benefits.
An application for benefits should be filed as soon as the person believes he or she will not be able to work for medical reasons for at least 12 consecutive months. You can apply at your local Social Security office or by calling Social Security's toll-free number, 1-800-772-1213 (answered from 7:00 a.m. to 7:00 p.m.). General advice about completing the disability application was contained in Part Two of this series.
What determines the strength of a disability claim?
There are many important factors. They include your diagnosis, medical test results, clinical signs and observations by your doctors, your symptoms and functional limitations as reported in your treatment records and the active support of your treating doctor or doctors.
How important is my diagnosis in my disability claim? To be found disabled, an individual must have a medical diagnosis. It is never the diagnosis, however, that results in a disability finding. There are many people who suffer from medical conditions who are still able to work. Decision makers in these cases are well aware of that. Therefore, a diagnosis alone carries little weight in the finding of disability.
What is the most important factor in determining the outcome of a disability case? Almost without exception, the most important factor that distinguishes successful cases from unsuccessful cases is how well the individual's symptoms and functional limitations are recorded in their doctors' treatment records. The most important symptoms to report are those that would prevent you from working on a sustained basis. The most common ones are pain, fatigue (including caused by side effects of medication), depression, anxiety, and other memory or concentration problems. If you are experiencing any of these symptoms they should be reported to your doctor on every visit and you should ask your doctor to write them into your treatment records on every visit. It is your symptoms that will prevent you from working, not your diagnosis. If you do not report symptoms that would prevent you from working, then Social Security will assume that you do not have those symptoms. This is a severe disadvantage for individuals who are reluctant to report the true nature and severity of their symptoms, for whatever reason. Unless your disabling symptoms are reported regularly and frequently in your treatment records, Social Security will assume that they do not exist. On the other hand, if your disabling symptoms are reported regularly and frequently in your treatment records, they will be given great weight and can lead to a favorable disability decision as long as your disability claim is also supported by your treating doctor.
What is the best way to make sure that my treatment records accurately reflect the nature and severity of all of my symptoms? We recommend that our clients keep their own written record of their symptoms and functional limitations in a composition book. Notations do not need to be made on a daily basis, but should be made whenever symptoms are at their worst and at least once a week. We then recommend that our clients take that composition book with them to every medical appointment and to read through it with their doctor to make sure that they report all of their symptoms. As discussed above, you also want to specifically ask your doctor to record those symptoms and functional limitations in your medical chart. If you have symptoms that are observable (such as swelling, redness, warmth, coolness or restricted range of motion) those should be noted as well.
What types of functional limitations should I report? It is important to report functional limitations because they serve as examples of your inability to perform work activities. Examples of limitations to report to your doctors include the following: inability to sit, stand or walk for extended periods; inability to lift more than 5 or 10 pounds; difficulty getting enough sleep at night, the need to take naps during the day, need for assistance in doing shopping or household chores, inability to drive, difficulty concentrating (such as to read), vision or hearing problems, limited or significantly reduced ability to use one's arms, hands or fingers (such as to grasp, write or use the buttons on the telephone or computer). This list is not meant to be complete, but to serve as examples.
If you or someone you know has any questions about disability benefits, call the Disability Benefits Law Center for a free consultation at: 215-886-0660 or email us at: info@disability-benefits-law-center.com The Disability Benefits Law Center maintains offices in Center City Philadelphia and Jenkintown. The Disability Benefits Law Center focuses its practice exclusively on Social Security and private disability matters.
