By Scott B. Elkind, Esq.
A physician’s medical record is typically based on the “SOAP” principle which means:
- Subjective data obtained from the patient or others close to him
- Objective data obtained by observation, physical examination, diagnostic studies, etc.
- Assessment of status
- Patient care
If you ever take the time to read your medical records, you will discover that the time
spent addressing your symptoms is very limited. It is your job to make your physician aware of
the severity of your problems. Further, the typical medical record will not record functional
impairments you are having in terms of bodily movement, ability to perform postural changes,
lifting/carrying, cognitive abilities, driving ability, inability to perform daily activities, and the
In this modern day of managed (read, “damaged”) care, your doctor is typically running
behind and a bit rushed to get to the next patient. You need to realize that you are the customer
and are paying for his/her time to make a full and complete evaluation of your entire person, not
just the most important complaint of the day. Therefore, it is incumbent upon you to make sure
the physician records the various problems you are having as well the effects on these problems
on your ability to perform work and life activities.
In describing your symptoms to your physician, makes sure to describe the problem in
terms of frequency, severity and duration. Simply describing things as “occasional,” “once
every so often,” etc., has no meaning and will be used against you in your disability case. You
need to quantify the problem. For example, instead saying: “It hurts after a walk a little bit,” you
should quantify the statement in such a way as “After walking two blocks, my back begins to
ache so bad that I need to rest for 15 - 20 minutes until it stops.” As you can see, the second
statement is much more precise and gives much more useful to the physician as well as
demonstrating your disability to a medical reviewer. The worse thing you can do is state that
you are feeling “o.k.” or “a little better” when you clearly are not. Such statements will come
back to haunt you as they will be used as evidence of improvement in your condition
If your physician seems overworked and cannot focus, then bring him/her a summary of
your problems to be added to your record. This helps you to remember to tell the doctor
everything and a summary to be utilized as part of your ongoing medical care treatment record.
You can also keep a diary of your symptoms to show your provider for this purpose.
Whether you know it or not, gaining the support of your physician for your disability
claim is critical. If your physician states that he or she does not “get involved in disability
claims,” then you will need to find another physician who will assist in supporting your claim.
You can be certain that the reviewing physician for an insurer or SSA will not be supporting
your claim. Without strong evidence from your treatment providers, overcoming the
contradictory (and, in many cases, ridiculously so) opinions of the defense physicians will be all
but impossible. In fact, SSA gives greater weight to your treating physician opinion. So, you
need to take advantage of this legal presumption.
Many physicians do not understand that for a person to be disabled does not require the
claimant to be bedridden. Further, the disability does not need to be permanent in nature to
qualify for benefits. If you are unable to work, it is important for that to be recorded in your
For these reasons, it is your duty to engage your physician in the dialogue concerning
your disability claim (whether active or pending). By doing so will assist you in understanding
if your physician will be supporting your claim and to what extent. Better to know early than
having to repair the damage caused by a physician who is not supporting your claim and learning
about only after you have filed your claim. As you were always taught, it is better to be safe
than sorry. In this instance, doubly so.