Social Security is increasingly relying on computer systems to evaluate disability. These systems both check the accuracy of decisions and try to identify claims that can be approved earlier in the process. However, they rely intensively on natural language searches of the medical records as well as coding done by SSA employees. Recent proposed rule changes will make SSA even more reliant on medical records for disability assessment, as opposed to opinions from your doctors. With this in mind it is extremely important for you to be aware of problems with the accuracy of medical records and to know what needs to be documented in your records.
Most people assume both that their doctors write down the necessary elements to establish symptoms and diagnosis and that they write those things down accurately. Multiple studies of medical record accuracy have established that this is simply not true. For example, one study found that that emergency room doctors failed to diagnose mild traumatic brain injury when the elements were present 56% of the time. Powell, Janet M., et al. “Accuracy of mild traumatic brain injury diagnosis.” Archives of physical medicine and rehabilitation 89.8 (2008): 1550-1555. Another study found that medical providers were particularly poor at documenting symptoms and medication side effects in schizophrenia patients, especially when those patients were severely ill, black, or perceived as non-compliant (meaning that the patient did not follow the medical provider’s recommendations for treatment). Cradock, Julie, Alexander S. Young, and Greer Sullivan. “The accuracy of medical record documentation in schizophrenia.” The journal of behavioral health services & research 28.4 (2001): 456-465. The problems with accurately documenting medication side effects, dosage, and drug allergies have been documented in multiple studies. A study from 1989 found that “Medical records are being distorted and fashioned to keep clinically important but sensitive personal information about patients from public view. To comply with standards of care and a reimbursement system blind to biologic diversity, medical records are being forced to address only the technical side of care.” Burnum, John F. “The misinformation era: the fall of the medical record.” Annals of Internal Medicine 110.6 (1989): 482-484. This study cautioned against what has now become a reality of modern life, over-dependence on medical records for legal determinations such as eligibility for disability benefits.
The problems shown by these and other studies are particularly relevant to those seeking disability benefits because the disabled are generally very poor and have a difficult time complying with treatment recommendations.
So, what can you do to improve your own medical records.
The first thing to do is have a conversation with your doctor to let him or her know that you are applying for disability and that as a result you will need complete and accurate documentation of your symptoms and documentation. Social Security has very specific requirements for diagnostic documentation and the only way for those requirements to be met is for your doctor to make sure they appear in the medical records. You will also need to have your doctor document the extent and nature of your disability with specific descriptions of your functional, especially work-related, limitations. For example, if you have a back condition it is essential that your doctor describe any difficulties you have with activities such as walking, standing, sitting, lifting, carrying, concentration problems due to pain, etc.
The next thing to do is to be open and honest with your doctor about your symptoms every time you go. Many people will assume that since they have told their doctor once they don’t need to do so again. The problem is that Social Security needs to see how your condition affects you over a long period of time. If your limitations are not documented consistently throughout your record, Social Security is very likely to find that your condition is not as severe as you say it is.
Next, help your doctor by documenting your symptoms yourself. For example, you can keep a journal or calendar that keeps track of both how often you have symptoms and how severe they are. If you have depression it is a good idea to document those periods when you have severe depression that keeps you from functioning. Then you can take that documentation with you to your doctor’s visits to make sure they are aware of how limiting your depression is. Often times Social Security judges will think you are lying if you tell them you have very severe symptoms despite taking medications or seeing a doctor regularly. They think the doctor would take further action like changing your medication if you were really that bad off.
Lastly, make sure you document any difficulties you have obtaining medical care. If your doctor prescribes a medication that you can’t afford, make sure to let the doctor know you can’t afford it and have the doctor write that down in your records. The same is true for any other medical treatment such as a surgery or a recommendation for physical therapy, and any other reason you don’t get treatment such as unacceptable side effects or transportation problems.
Taking these steps will not guarantee that you will be approved for benefits, but they will go a long way to helping you prove your claim.