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Old 10-14-2013, 09:29 PM #1
St George 2013 St George 2013 is offline
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Default Why are doctors notes so brief ? (for ssdi)

I just don't understand....I picked up 2 currents doctors reports today and even though I had a 15 minute conversations with both of them, they skim over what I consider the important things we talked about and what would actually help me in my reconsideration appeal.

Don't we pay them enough for them to put detailed notes in ?

Thanks for listening....just very frustrated with this whole process.

Debi from Georgia
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Old 10-14-2013, 11:34 PM #2
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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.
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Old 10-14-2013, 11:48 PM #3
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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.
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Old 10-15-2013, 12:38 AM #4
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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.
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Old 10-15-2013, 12:43 AM #5
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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
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Old 10-15-2013, 02:09 AM #6
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Default Thanks Hopeless and finz for ur quick response :)

I've been seeing my PCP for almost 6 years. She and I have a great relationship but she WILL NOT fill out the ss forms for me. She keeps saying ss will send me to their dr's and that it's obvious I can't work. (Oh how I wish ss would send me to one of their dr's !)I did get her to put in my visit notes that I am disabled in her opinion. I also saw my onocologist and he put in his notes that due to the neuropathy I was unable to drive, grocery shop or basically leave the house. That's about as far as I got with them. They did both not that my neuropathy was caused by my diabetes and chemo treatments.

finz: My foot dr did the skin punch biopsy and the results were positive for SFN. He said my results were 0 out of a possible 15 and that it shows my feet are devoid of fibers A and C. He also went on to state that my only option at this point is to see a pain mgmt. specialist who might be able to improve my quality of daily life enough to at least let me drive and grocery shop. He put NONE of the above in his report. Said he went over the results with me and was referring me to a pain specialist. I was stunned when I got the records and called his office advising I really needed him to put in the records what we had discussed. She said the results of the test were enough for ss.

Guess that gives you an idea of what I am dealing with. My symptoms are getting worse. I now have swelling on the bottom of my feet, the numbness is worse and so is my balance. I've also noticed the hair on my legs is not growing like it was...I'm only 51 you know ?

I do not have an attorney....I did talk to an advocate locally and he put some wording for me to use on the reconsideration. Basically said it was a crap shoot. Depended on who looks at my reconsideration, how they feel that day, if they feel like I'm on the fence as far as approving they may approve if they have already denied a lot.....just on and on.

My whole life has been completely turned upside down in 1 year.....1 YEAR is all it took....crazy......lost job of 26 years, 2 months later I was having chemo that didn't end until March of this year and then BAM....a month later I couldn't walk. I say I still have chemo brain but I'm wondering whether it's the SFN working it's magic.

Thanks for coming back to me and if you read this response and have more to add please do. Neurotalk is the best thing that has happened to me this year !

Debi
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Old 10-15-2013, 09:27 AM #7
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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.
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Old 10-15-2013, 10:28 AM #8
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Default 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]
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Old 10-15-2013, 12:39 PM #9
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Originally Posted by finz View Post
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
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
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Old 10-15-2013, 01:39 PM #10
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Quote:
Originally Posted by St George 2013 View Post
I just don't understand....I picked up 2 currents doctors reports today and even though I had a 15 minute conversations with both of them, they skim over what I consider the important things we talked about and what would actually help me in my reconsideration appeal.

Don't we pay them enough for them to put detailed notes in ?

Thanks for listening....just very frustrated with this whole process.

Debi from Georgia
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.
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