Social Security Medical Records

Posted on June 2, 2008 by Dory Sutker
I’m not a doctor and I don’t play one on t.v. but, as a social security disability attorney, I have read a mountain of medical records. I’ve learned a lot through the years including how to decipher some really horrible handwriting. But, one scary thing I’ve noticed is that the records are rarely completely accurate. Some of the inconsistencies may be relatively minor and totally inconsequential to a social security disability claim. But, others can be extremely problematic.

Simple typos can create huge obstacles. For example, if the physician leaves out an important word like "not ", the whole meaning of the notation can change. And it may make all the difference in the world. For example, the doctor may write, "the patient states that he can walk 1 block without pain" when he meant to write "the patient states that he cannot walk 1 block without pain". You would be surprised how many mistakes like this happen.

Sometimes the error involves identifying the wrong extremity. This can lead to confusion, or in some cases, it can lead to a question of credibility. I see lots of incorrect data and it can lead to many problems including questions of identity.

Grammatical errors account for some of the problems. Simply using the wrong tense can create difficulties. Notations such as "patient is an avid hunter" instead of "patient was an avid hunter" can lead to misperceptions of current functional capacity.

In an effort to save time, some physicians use forms for their report format. On these forms, some have a category for sports/hobbies. If the physician fills in "bowling, fly fishing, and woodworking", one can easily interpret that to mean the patient still engages in such activities.

What can you do to minimize your chances of errors on your medical records? One thing you can do is to be careful to articulate your medical problems and any side effects from medications. Do this each time you visit your doctor. Otherwise, he/she will write a notation that you said you"felt fine". (See previous blog for discussion of this subject) What else can you do? You are entitled to copies of your medical records. (CAVEAT: The doctor can charge you a fee for copies.) You can get copies of your records and review them. Then talk to your doctor about any discrepancies.

Some of my clients explain to their doctors that they have filed an application for social security disability and that, therefore, their records need to reflect their impairment(s) and its effect on their functional capacity. Let me know if you have other suggestions for dealing with this rather pervasive problem.

To learn more about social security disability law issues please click social security disability law. To learn about our social security disability lawyer in Maryland, please click social security disability lawyer.

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