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COSTLY MISTAKE: Creating Bad Medical Records

When you get sick or injured only you know the full experience and extent of your limitations and pain. You are the one dealing with illness and/or injury and will have an opportunity to describe this to disability examiners and an administrative law judge. This, however, is not legally enough to prove that you are disabled. There must be a foundation of solid supporting medical evidence for a successful Social Security Disability Claim.

The following are 5 ways to help avoid a costly mistake and create a foundation of solid supporting medical evidence:

  1. Treat early and treat often. If your illness or injury is bad enough to keep you from working, then it is bad enough for you to seek medical treatment. Consult a doctor as soon as possible. If you do not have medical insurance and cannot afford treatment, please apply for Medicaid with your local Department of Social Services.

  2. Follow reasonably prescribed Treatment. If you fail to follow your doctor's recommended treatment then Social Security law can keep you from receiving benefits. What if you disagree with your doctor's treatment plan? First, remember that your doctor is a practicing expert in his or her field and, generally, has your best interest in mind. If you feel strongly that your doctor's recommendations are wrong, talk with him or her about your feelings. If the issue persists, you may want to obtain a second opinion from another doctor. Second, under no circumstance should you completely disregard what you doctor prescribed without attempting to resolve your concerns.

  3. Explain your pain and limitations in detail. A great way to make your claim credible is to describe your experience of pain or other limitations in great detail to your physician and have them included in your medical notes. Instead of saying "the pain is everywhere and I can't do things like I used to" say "the pain is in my lower back and often goes down both my legs to the knees and I can't twist or stand for more than 10 minutes without being in extreme pain and forced to lay down. Also, the pain medication makes me tired, dizzy, and nauseous, so I generally fall asleep a couple hours every day." This is an effective explanation and you should use this level of detail when talking with your doctor and make sure that those details are recorded in your medical notes.

  4. Keep personal logs. This is another way to show the credibility of your pain and other limitations. Document all events of pain or other limitations in detail in a personal journal. For example, if you suffer from seizures you should record the date and time of each seizure, along with the type, intensity, recovery time, and any other relevant information of the event. The same log can be used if you suffer from migraine headaches or have any episodes of any body pain. This gives the SSA a tangible view of the on-going severity and credibility of your condition.

  5. Consult Specialists. Specialists are doctors who focus solely on one area of medicine. These doctors generally have more expertise with one specific are than your primary care physician. You should speak with your primary care physician about your particular issues to determine what type of specialist you should consult. A specialist's opinion regarding your condition is going to be much more persuasive to a judge than a general doctor's opinion. Getting an early initial diagnosis or a later confirmation of a previous diagnosis from a specialist will add credibility to your claim.

Call us today to see how we can help you with your claim and medical records! 423-771-HELP (4357)

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