My medical records are giving me a headache.
 

I requested copies of all my medical records so I knew what social security was getting. I'm noticing some damning trends- doctors seem to like to document things to be thorough that the assume and never actually asked you, doctors like to document inaccurate information, and doctors seem to make a lot of straight up mistakes.

It is absolutely clear at this point that I'm going to be denied and will continue to be denied until I get more documentation and things clear up. Man, if I didn't know that these records belonged to me, I would think the person was med seeking because the pain levels, areas, and associated symptomology keep changing. I don't think I'm ever going to be approved. Then there are the comments asserting that everything is good- when they never asked! So I have plenty of "concentration is fine" documented- until right around when I applied!

I'm so frustrated and there are so many errors that I don't even know how to go about getting them resolved. I, quite honestly, don't have the ENERGY to get them resolved.

On top of that, I'm finding some things that were significant- but NEVER MENTIONED TO ME. Some things are small like mild mucosal disease (which in severe cases can cause death- but obviously it's not worth mentioning) but other things are quite important- like that I'm rubella non-immune when I'm caring for a premature baby. Or that I have a freaking 6x6x3cm cyst on my heart that requires regular MRIs and follow ups. WTF.

I would speak to each doc about their errors or oversights. Their responses would impact my decision to keep them on my treating doctors list. If each of them aren't fully in your corner, you don't want to keep working with them.

What a mess.....I'm sorry that you are dealing with this, LLT

Thank you so much for your kind words.

The thing is, NONE of these doctors are really current treating physicians. My PCP has moved to a new practice that doesn't accept my insurance and it took me many visits to many different specialists to find out what my diagnosis actually was. I have documentation saying I'm male on one visit (a "well developed male" which really made me laugh), one saying that I have inappropriate judgement and insight in social situations with no further explanation- I honestly think they wrote inappropriate when they meant appropriate because I don't even drink and certainly don't use drugs! I've never gotten so much as a speeding ticket! How much lack of judgement must I have? LOL. I was also on a medication at one point that was approved for siezure disorders/bipolar disorder but was being used off-label for treatment resistant depression. I tell my doctors that I do not have bipolar disorder, sign a release for them to get my records, and explain that I do have major depressive disorder- I get documented as having bipolar I and II which isn't even possible. I tell a doctor that I have sympathetic nervous system disregulation that looks a lot like PTSD per my neuromuscular physical therapist but that I did not have PTSD but it was documented that I had PTSD and not the disregulation which is common in people with Ehlers-Danlos which I DO have! I get documented as having generalized anxiety disorder, depression, major depressive disorder, post partum depression, post partum anxiety, and mood disorder NOS when, in reality, it's just freaking plain anxiety and depression. That's it! It's not even possible to have all these diagnoses at once!

It took me 2 years to finally get SSDI. I had to appeal and appeal and appeal all the way to the last where we would sue in federal court. my surgeon said clearly, "...she is totally and permanently disabled...unable to work." but because my diagnosis was not in the SSDI diagnosis book and was a new medical disorder, the worker automatically denied my application. The other stumbling block was that I had lots of education and SS figured I could work --(?with my mind I guess...) I finally started receiving benefits right before we were to go into federal court to sue. I learned: tell the truth.don't ever quit. and LOTS of healthy people who don't enjoy work apply for SSDI benefits and make ALL of us look like bums so the SS folk get hardened to all people with disabilities. And I've learned that working is much better than living in poverty!!

A doctor stating a patient is unable to work and permanently disabled is not suffecient proof for SS. It's not their decision. Even when a person is sent to a SS doc, they don't have that power. I'm mentioning this for those in the process so they don't get confused. ;)

Well, if you aren't transgendered, then having that sex change operation would have been REALLY inappropriate judgement ! ;)

Okay, this one is my serious reponse ;)

I'll start by saying thay my chronic pain has caused me to use inappropriate judgement. I should KNOW by now, that if I do too much, I will pay the price for it. I should KNOW that if I want to go someplace and I need to drive, I can't be in severe pain, so I need to make sure that I don't do anything too taxing for a few days before that. Do I DO that ? Ah.....NO ! I'll plan on not doing much and then I realize that there isn't much food in the house, so I have to get to the grocery store. That's good for a few days in bed right there. Then I miss the thing that I was supposed to try to drive through. Nevermind that getting to low on food wasn't the swiftest plan either..... That's ALL poor judgement.

Respectfully, I think your quote shows a lack of insight in this social situation. Using poor or inappropriate judgement doesn't have to be about being a druggie or getting in trouble with the law. It's definitely not about enjoying an occassional cocktail. Did the mention of a "social situation" lead you to assume the doc was referring to a party and implying wild behavior on your part ? That would be one extreme possible meaning of what he wrote. Where there is no supporting documentation to explain that, another health care professional would take the docs words just to mean that you are not always able to make the correct decision (like me, above) or take the wisest course of action. The lack of insight in social situations just means not "getting" or fully understanding what is being discussed.....just as it seems you assumed the doc was making an accusation, and not HELPING your case by defining some mental deficits. That is a lack of insight into the meaning of this situation. Does that make sense ?

I think a challenging part of having a disability claim including a mental health component and reading all of the documention is that it can appear to be a little insulting. We have to realize that if mental health issues are contributing to our disabilies, some things will be documented that don't sound like "admirable" qualities. I'm not PROUD that pain and stress cause me to use poor judgement at times, but I have to admit that it's true, for me. I don't know you well enough to SAY you also have this problem, but I can say that it would be highly unlikely that someone with chronic pain issues, depression, and anxiety doesn't exhibit poor judgement on occassion. That is part of documentation PROVING the diagnosis. Off the top of my head, some other words my therapist might use to describe my mood or affect could include: easily irritable, ruminates on small details, angry, lack of self worth, lack of energy, poor organizational skills (okay, I had that before I became disabled too), feels like a failure......All of those things are "negative" qualities, I'd prefer they didn't describe me, but they do. That all should be on an SSDI claim, if applicable.

Having my brain not work as well as it did before is part of my disability. It doesn't make me a stupid person, but it does make it very difficult for me to access that "smart" part of my brain through the fog, a lot of the time. That's part of the reason that I can't work. I feel "smart"/okay right now but not when I'm in bed, in pain, begging one of my kids to get me an ice pack and a pill to just make the pain stop. Talk about poor judgement.....sending the teenagers to juggle the narcotic bottles. NOT a good plan.

Okay, I'm blabbering, so I'll stop on that subject. Thew moral there is to try not to be offended by things the doc has to write to prove their dx and hopefully prove your claim of disability.

Regarding the mess of all of the misdiagnoses, a new doc can clear all that up by just referring to the correct dx's going forward and preferably, they could also write a little blurb to the effect of, "patient reports excessive worrying (trust me, that can only help your claim) about earlier misdiagnoses and incorrect documention of past medical professionals. Patient has X, Y, and Z diagnoses. Her symptoms are A, B, and C. These symptoms make her totally disabled and unable to work (this part means NOTHING to the SSA if written by itself) because she cannot tolerate INSERT IMPORTANT STUFF FROM YOUR RESIDUAL FUNCTIONAL CAPACITY FORM HERE. THAT is the part that proves disability to the SSA.

I can tell you that I saw a lot of similar documention errors and outright lies in my paperwork. The outright lies all seem to be from the doc I had to see for worker's comp. I might have expected him to minimize my complaints to say that I could work when I couldn't, but the just plain LYING, I don't get......like saying that I said I had no discomfort driving myself to the appoinment with him, proving I was able to drive, when WC had to provide transportation because I could not drive, so they paid for and sent their own taxi service to get me. What the heck ?

That type of stuff was most of my record for quite awhile, because my disabling condition is primarily what my WC injury was, so it was THEIR docs doing all of the documentation. Not very helpful in an SSDI claim.

The documentation changed after I demanded a doc of my chosing and I finally started getting some treatment to help manage the issue.

You don't get that removed from your SSDI application, you get better documentation from docs with a clue as you move forward.

BAD documentation
 

I am so sorry to hear that you also have experienced BAD medical documentation. During an office visit I had my "former" PCP ask if I was still taking a particular prescription. I had no idea what he was talking about and had never heard of the medication. He said that it had been prescribed for my gastrointestinal issue by another specialist, whom I also had never seen. I asked him whose chart did he have in front of him as I did not and had never had any gastrointestinal issues nor had I seen the other physician he had named. After confirming he did indeed have MY chart, he said he may have made an error while cutting and pasting his notes into the computer. After the encounter, I requested copies of my file, and found numerous errors in my chart. He refused to correct my records. I immediately changed docs but SS disability got ALL of my records including the erroneous ones from the medical complex.

Wow.....you've had AWFUL luck with the medical records throughout this whole process with multiple errors by others. Many of the really knowledgeable posters here frequently discuss the importance of reviewing the whole medical record/SSDI application to make sure the info that proves disability is in there. You've had to deal with missing documentation that you hand delivered to the SSA and the wrong records copy/pasted into your records.....Ugh ! Your screen name is making more and more sense ! :hug: I thought is was "just" about your medical condition. So sorry that these outside forces are making a dismal situation even worse. You deserve a break. My prayers that your situation gets better, somehow.

Not on the dx list
 

Glad to hear you were finally successful. I had two jobs, simultaneously, which I dearly loved. I finally had to quit when my pain reached the point where I could no longer perform my job duties. I have several conditions in addition to my primary reason for leaving the workforce, when taken alone, are not severe enough to qualify but I was under the impression that would be considered like icing on a cake. Example: After a cardiac cath and unsuccessful attempt at stent placement for a 90% blockage in coronary artery, (not an artery in their list), and angina upon any type of exertion, just walking to the mailbox, I thought that might be considered since it is on top of my primary condition that forced me into near shut-in state of life. I have exhausted my life savings just to keep afloat. I now borrow money every month just to pay my health insurance, which I can not be without. I am 62 and do not know if I can hang on till 65 for Medicare coverage. If I were approved for disability, having Medicare would be a great help. I will have met the two year requirement if they include the year prior to my claim, which is documented.

Thank you so very much for being here for me and others.