Why are doctors notes so brief ? (for ssdi)
 

Hi Debi,

Oh, there is so much I would like to say in response to your post. I understand your frustration. Not only do records lack a lot of information, they also sometimes contain erroneous information and opinionated information. I have even typed things out and faxed them to my doc before my appointment so that there is written evidence, I don't forget to mention some items, and it is complete, at least on my end.

In obtaining copies of my records for disability claim purposes, I was shocked at what I discovered.

For purposes of medical records, there are different schools of thought and variations on what should and should not be noted.

If it is not written, it did not happen. Don't write any more than is absolutely necessary.

The above is what I was told by a nurse once about what is charted.

I have found notations in my records stating I was on medication that I have never taken or even heard of and have been referred to physicians I have never seen or met. I have also received records within my own that were for other people.

Two of my doctors have changed over to electronic records instead of paper charts as is now being required. A big advantage is you can read it since it is typed and most docs have handwriting that no one can decipher. The problem is when they move from screen to screen, they have a much greater chance of entering information in the wrong location and you wind up with erroneous records. This has happened to me. When I was at an office visit in September, my doc referred back to my prior visit from August. He was still in the August screen and did not realize it and posted the September details under the August visit. You would think no big deal but it looked like I had treatments before I had treatments and results from treatments were indicated before the treatements were performed.

I could go on and on and there have been many discussions in other threads about medical records.

Sorry I got so winded. I just wanted to say I do understand your frustration.

Hi Debi,

A lot of information that SSDI wants about your limitations are generally not included in doctors notes. The way to get that information in front of SSDI from your doctor is through a Medical Source Statement, similar to an RFC used by SSDI.

An RFC is very similar to a Medical Source Statement except an RFC is completed by SSDI and an MSS is completed by your docs and submitted to SSDI.

If you do not have these type of statements from your docs, only copies of your medical records, I would strongly suggest that you have your docs complete Medical Source Statements as soon as possible.

I had a doc very supportive of my claim but it took 3 months to finally pin him down long enough for him to complete the form for me. Another one of my docs filled it out during one of my office visits on the spot. It all depends on the doc.

Hope this helps.

I forgot from your prior posts, are you represented by an attorney? If not, you can get a medical source form from the internet and take it to your docs. If you do have an attorney, he can supply you with a form or he can send a letter to your docs with the form asking that they complete it. Patients usually get a faster response from docs than attorney request for it.

Hi Debi,

It is a very frustrating process.

"Don't we pay them enough for them to put detailed notes in ?"
Usually ? No, we don't. Most docs book patients in 15 minute increments. If you "used" up that whole 15 minutes talking, he doesn't have much time left for documentation.

I have the same "wants" from my docs as you.....for a thorough job that adequately addresses our concerns and medical needs. That doesn't come automatically, as many of us feel that it should.

I've heard that some doctors charge a "consultation fee" to complete the documentation needed for our ssdi applications. Personally, I feel that's ridiculous, that completing the paperwork to help us collect ssdi is part of their job. If a doc doesn't feel the same, we have to choose between switching docs or trying to compromise/work with them. I understand that the ssdi paperwork takes extra time. I want my doc to understand that he can shave some time off discussing my high blood pressure or diabetes. My pain issues and stress over ssdi (and the health insurance that MC will provide that will be necessary for my future medical care) are absolutely as critical to my health and long term survival as my bp. While I believe docs SHOULD help with the ssdi paperwork as part of our regular care, if it took paying a consult fee of a few hundred bucks to get an hour of my docs time to do it right, I'd do it.

You might check with your docs to see if you may have to set up a special time with them to manage the ssdi application.

I think it's important to consider that a doc's "normal" goals in documenting a patient visit are about whether or not his findings are expected and what his medical plan is to treat symptoms that a patient experiences. That's his legal requirement. Unfortunately, that doesn't do much to PROVE disability to the SSA. Your doctors might not understand exactly what you need the focus of their documentation to be to help you get approval.

Was your 15 minute conversation about your health issues related to your disability or was it about completing documentation that shows how your symptoms make you disabled ?

I wish this process wasn't so complicated.....and that you didn't feel like you were back to square one with this. Good luck, Debi.

Hey, no fairsies Hope ! I started my post before you made your posts !

I was pokey with typing and my brain working, so you beat me......and said it better !

Glad that you were feeling decent enough to post :hug:

Thanks Hopeless and finz for ur quick response :)
 

tell the pcp that you will pay her for her time filling out the forms that you need. that may change things. otherwise your relationship with your pcp really isnt as good as you thought it was.

Woke up still ticked off :)
 

[SIZE="3"]I have offered to pay a fee if needed to get some help from her with my forms. She works for a huge company (Emory) and since they took over our local clinic the dr's are afraid to breath the wrong way !

The neuro, I only went to once, did not even want to talk to me about disability as he said I could wake up the next day and it could be gone......I wish ! That was before the skin punch biopsy. Most of my medical problems have been regular stuff prior to this past year. Sinus issues, had gallbladder taken out, the usual. I've never had any dealings with a neuro, a foot dr or a pain mgmt. dr. And I've had to decide on my own to go to these dr's. I also had to ask for the biopsy but am so glad I did. It was a relief to get a diagnosis even though it sucked.

This has been so rapid in it's progression it scares me but I don't tell the husband or kids. The bottom of my feet are now swelling, the numbness is worse and spreading....aching to my knees and my hands are starting up again and too much more to list. I also have what I call 'female cramps' but had a hysterectomy so is that SFN too ? So many dang questions.

When I say rapid I mean starting approx. May 1st of this year ! Diabetes/chemo related.....had taxol/carbo for 6 rounds and the chemo nurses said it was strong and they aren't surprised I'm having this much trouble. Wish the nurses could fill out ssdi paperwork...lol

Please comment...I learn so much from all of you...Great peeps

Debi (nice and cool this morning in Georgia)[/SIZE]

Thanks
 

That was too cute. Made me chuckle. Nope, you are much much better at explaining things. Where do you think I got all my information from? YOU.
I will never be able to thank you enough.

Hope

One more comment
 

Hi Debi,

One more comment from this peanut gallery.

I have learned that qualifying for SSDI is not based upon medical conditions. I meet more than 2 of their listings and the medical review stated that I have "severe conditions". To quote ...... "severe but not limiting".

Physicians that do thorough charting do not indicate how your medical conditions limit you and that is what SSDI wants.

In other words, my conditions are serious and could KILL me but they should not prevent me from working.

Finz says it best. It really is not about WHAT you have but HOW it limits you. That rarely ever shows up in doctor's notes.

I know the frustration of getting the proper assistance from your doctors even if they are in full support of your claim and believe that you are unable to work. They need to say exactly WHY you can not perform substantial gainful work.

Since you are having so much difficulty getting your doc to complete the form needed, maybe you could do the paperwork and present it to your doc. Then all they would have to do is review it and if they agree, sign off on it.

Sounds unlikely that your doc would even be willing to do that but threw that out to you just in case.

Good luck.

From Research
 

The following is NOT based on personal experience but on research I have done.

I would not put too much hope on reconsideration unless you have provided additional information as the number of claims approved during reconsideration level are low. An ALJ hearing is the place for more hope.

I do not mean to sound discouraging, just do not want you to be crushed if not approved at the reconsideration level. Several states have omitted the reconsideration level completely. You go straight to ALJ after initial denial if you appeal.

Going to one of the SSDI docs may not be helpful. From what I have read on some threads on neurotalk, you get a brief exam, seldom get to talk, etc.

As I said, both of these topics, "reconsideration" and "their doc" are not things I have any personal experience with and only offer info that I have read. Hopefully, someone with more experience will be able to give you better information.

I certainly wish you the very best and hope that you can obtain assistance from others here, from your physicians, etc.

Keep us posted. A lot of us are in the same boat. Wish we had some life rafts. :)

not to put too fine a point on it, but if your doctor wont help with any paper work, then they are pretty useless to you now at reconsideration stage and in the long run when you may have a hearing before an alj or even later if you are found disabled and have to fill out long form cdr's. since you will always need your doctor to fill out one form or the other, you should be out looking for a new one. most of us have had to do so. i had a great pcp but since that doctor moved to another state i have been through five and am on my sixth in the last 4 years. its just too important for those of us on ssdi or applying for it to have a co operative doctor.

Here's a link to provide an RFC form for your doc/s to fill out. This should not take her long.

http://www.ultimatedisabilityguide.com/rfc_forms.html

Expecting a SS doc to advocate for you is very unrealistic of your doc. They'll review your medical records and not sabotage your claim if you're lucky. You want to have RFC form/s in your file before you see the SS doc/s.

Thanks echoes long ago. You are very correct about Debi needing a doc that WILL help with paperwork not just now but in the future with the continuing reviews once approved.

I think Debi is in a difficult situation as it is hard to change docs in the middle of an appeal.

I do not know Debi's financial situation or insurance coverage but maybe seeking a "second opinion" from another doc, including her quest for a new, more willing doc, might be beneficial.

Finding the right doc is not an easy task.

echoes long ago makes a very good point.

Debi, would you even consider another doc since you have a good relationship (other than the lack of cooperation of paperwork)? Maybe you could approach your doc with the tactful message that you NEED a physician that is supportive and although you wish to remain your docs patient, you really need his/her help.

I feel your frustration and do not have an answer. (Wish I did.) I know how difficult it is to seek out a new doc when you like yours, but you also need their help with more than your immediate health care, you need them to document your health. Finding one that you trust and will complete paperwork is a daunting task. Good luck with whatever choices you make.

Maybe I can.....
 

Your doc could also refer you to a physical therapist to test you for the RFC.

If your hands or wrist swell from typing or writing, a pt can measure this with a water displacement test. If you lose strength after engaging in certain activities, it can be measured, etc. Essentially, physical evidence will help you much more than subjective complaints.

I agree if your doctor isn't willing to do the documents or notations you've asked for it may not be as great of a relationship as you think.

After seeing some records from my Pain Doctor I have asked he include certain things in his notes and how they effect my ability to (not) work and effect daily living.

Thanks everyone for the info and.....
 

I have an appoint with an orthopedic next tues and they have a PT dept there. I'm going to ask if they can do the RFC for me even if I have to pay for it.

If I have said that before now please excuse the duplication. I'm not feeling great today after seeing or 'not' seeing my 2nd pain mgmt. dr.....saw his assistant.

I finally rec'd a letter from my new case worker and she is with Georgia Vocational Rehab. Have to fill out more forms and since my symptoms are worse or I have new ones it was hard to fill that paperwork out. When you see what u can't do anymore it is kinda of depressing. But I need to call her today because I have to add a dr appoint I had last week, the one today and the one I have next week. That should leave my file open long enough to get in to the PT dept for the RFC.
Say a little prayer and keep your fingers crossed for me.

Going to bed....I feel like poo because I had to go out.

Debi