There are many reasons why a Social Security disability claim may be denied, but the most overlooked is what your medical records say or don’t say. in this age of HMO medicine, doctors spend less and less time face to face with the patient and even less time charting or dictating their findings. On average, a doctor may spend, on the high end, 15-20 minutes with a patient and 2-3 minutes charting or dictating their findings. Anyone who sees medical records knows this has led to medical records by checkbox or copy and paste. In other records, doctors will write so quickly that the records are difficult to decipher, especially after being photocopied, faxed, or scanned. In your Social Security claim your records are very important as they carry significant weight with the administration.
But what does this mean for your Social Security claim? It means your records can become conflicting or even lack the objective evidence needed to prove your claim. For example if you have problems with your low back and your doctor does not check your range of motion and simply marks the box saying your muscular skeleton is “normal”, then Social Security interprets this as you are having NO problems that day. No pain, no difficulty with range of motion, nothing. I have seen records were the doctor has checked normal and then written exceptions to that on the side. Normally this is helpful because it clarifies what was or wasn’t normal, but only if anyone else can read the writing.
Other times the doctor will simply carry over findings from your previous visits and just add a small update to your records. While this shows that your conditions continue to bother you, many times doctors do not clarify that your symptoms are worsening or what the severity was at each visit. I have even seen cases where this has caused confusion in the record as treatment or diagnoses have changed over time with new information, but the copy and paste did not get changed.
Regardless of how a doctor records your visit, they cannot include in your medical records what you have not told them. You need to tell your doctor ALL of your complaint at each visit, even if that is not why you are there. It is as simple as saying, Doctor, I would like you to note that my back is still bothering and I am having pain. Also mention any side effects your having from your medication. The more information you tell your doctor and get into your records, the more your records can work to get you approved.