Honesty, Compliance, and Side Effects: How Medical Records Tell Your Story

In past blog entries, we touched upon the importance of continuous medical treatment as well as the importance of being honest with SSA. Today we will look at the importance of being honest with your doctor, your relationship with your doctor, how this affects your medical records and subsequently, your disability claim.

1.       Honesty: When a doctor asks you how you are, tell him!  Don’t give him/her the “canned” answer of fine, good, etc.  Most people with mental or physical disabilities do have good days and bad days, but be honest!  Examples:  Have you been in pain?  Maybe you aren’t today, because today’s a “good” day, but what about yesterday or over the weekend?  Are you depressed (due to pain, inability to work, etc.)?  Do you have a new symptom?  This is part of your written medical record.

2.       Compliance: This matters greatly in the eyes of SSA, as well as your doctor!  Examples: take meds as prescribed.  Go to physical therapy if referred.  Don’t miss counseling appointments.  Judges frown upon non-compliance issues and may deny you partially because you were not following your doctor’s advice to help improve your health.  This is part of your written medical record.

3.       Side Effects: All meds have side effects, some worse than others.  Fatigue, dizziness, nausea, diarrhea, etc. Tell your doctor!  In addition, when asked, list them on any SSA forms. Reports of side effects are just as important as the conditions the medications are treating, as they can also interfere with your ability to work.  This is part of your written medical record.

Doctors, nurses and other medical staff notate everything you tell them at your doctor visits. They also make observations regarding your presentation, such as if you are walking with a limp or you seem particularly depressed. Doctors and nurses can usually tell if someone is lying or exaggerating. This is also made part of your written medical record, and if SSA sees these kinds of notes, it ruins your credibility and may harm your claim.

If your current doctor does not seem sympathetic to your situation, or you feel you are not getting the proper care, it is OK to find a new doctor. It is a wide misconception that you must stay with the same doctor throughout the life of your disability claim. This is helpful if you have a good relationship with your doctor, but pointless if you do not. If you cannot clearly communicate your medical issues and consequently cannot get the treatment you need, it is important to start looking for a “second opinion.” Since the basis of your disability claim relies heavily on your medical records, it is vital to have treating providers who you feel comfortable with and have your best interests in mind.

It is vital to remember that YOU are the most important factor in your disability claim. Attorney representation can paint a vivid picture and submit compelling arguments for a finding of disability, but only if the underlying facts are there as found in the written medical records. The medical treatment record and the limitations opined by the treating doctors provide a strong foundation, and with this, we can help you build the Taj Mahal!

Written by Anna Westfall & Anita Feldkamp, edited by Paulette F. Balin & Andrew November

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