Why Are Details Important in Medical Records?

The proof in disability claims begins with the objective medical findings in the treating physician’s records. Office notes are often given more evidentiary weight than ANY narrative reports because they are made at the time of the visit and are seen as more reliable.

For Social Security disability, however, the focus is on the ability to function, not simply on diagnosis and treatment. For these disability claims, a physician’s statement that someone is “disabled” is meaningless without the documented clinical signs, symptoms, findings, functional limitations and medical opinions to support that conclusion. Doctors would sometimes rather be focused on indications that their treatment plan is providing relief, rather than proving disability and “failure” of treatment.

Many treating providers “chart for strength,” documenting each small improvement. This can be devastating to a Social Security claim if the chart does not also include continuing limitations. Unfortunately, this forces both the treating provider and the patient to focus on the negative aspects of the illness.

If the claimant cannot work full-time, then the doctor must document that opinion. If the doctor feels the patient can work, or is malingering, this must be explained to the patient so that the focus can switch to treatment and the return to work.

Eliminating financial stress by obtaining benefits can often allow patients to redirect their energies to recovery. Anxiety about bills and finances can sometimes exacerbate illnesses.

These benefit programs provide minimal cash assistance and more importantly, access to the health care system though Medicare and Medicaid. This continued medical care may provide opportunity for recovery and eventual return to work.