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 like.

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 medical record.

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.