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Documentation Is A Winner!!
Written By : Angela Davis-Morris 
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Documentation Is A Winner!!

By: Angela Davis-Morris

Originally published in Healthy Cells Magazine, July 2010

Good medical records can mean the difference between being awarded disability benefits and not. The Social Security Administration requires proof beyond "claiming" one can’t work. It has to proven through medical records; and that responsibility is on the claimant.

What most people don't understand is that just because they "know" that their doctor "knows" they have a particular limitation or medical problem, doesn't mean that the doctor writes it down every single visit; and if the doctor doesn't write it down, to the social security judge, it didn't happen. When people go to the doctor for "RX refills" or a "follow up", that's what the doctor/nurse writes down. But, they are really going to the doctor because they hurt, or their blood sugar is out of control, or their legs are swelling, etc. The doctor may write down something like "no complaints, needs refills." It looks like they have nothing wrong or nothing to complain about at the moment; they are just out of medicine. So, when a judge looks at the record, all he sees is that the person is out of medication and has no complaints. It sounds like they are well-maintained medically when actually they are not.

Also, some people understand from conversations with their doctor that nothing can be done for their particular problem (either because they don't have the insurance or funds to cover testing or meds, because it is not something that can be corrected, or because it is out of the particular doctor's expertise). The claimant interprets this as " it can't be corrected, no point in complaining" - - and they don't mention it again. It never gets noted in the medical records. So, to a Social Security disability judge reviewing the case, it simply isn't a problem and they will not accept that the claimant suffers with it.

People need to point out their medical problems and limitations on each and every office visit with a doctor so that these can be properly documented. Otherwise, they may well be disabled, but a judge won’t be able to find them disabled due to lack of documentation.

Medical records are extremely important to the outcome of disability cases. Because of how the rules/regulations are written, well-documented records (including specific limitations, symptoms, and causation) are absolutely necessary for a good determination AND they can make all the difference in the world to someone who has suffered a significant injury or illness and, because they now can not work, have lost their quality of life and maybe even their possessions, not to mention their pride. The satisfaction of being awarded disability benefits and being able to receive money from a system that one has long paid into, is a slight consolation for all the time, stress and effort it takes to get awarded. But, the monthly benefit and the assurance it brings can make all the difference in health, well-being and self-worth to many; not to mention make available necessary treatment.

The bottom line bears repeating, the claimant is in the position of proving the need for disability and the best way to meet the requirements is to have well-documented medical records, detailing the cause and treatment for each visit or phone call.

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