Proper Medical Documentation: Why It’s Important

When I was “younger” I trusted my (ex) doctors were taking care of me for years; until I realized they weren’t actually paying attention to my symptoms–only making assumptions–and not taking proper records. Because of that, I have been fighting for Social Security Disability over ten years later–and I’m guessing I’m going to be denied again this time around (it doesn’t stop hurting after all of these years, you just start getting used to being rejected… Personal tip: Never give up fighting for Disability if you believe you honestly and truly deserve it).

doctor-with-tabletWhether you’re disabled or not, it’s important to make sure that your doctor is documenting your case properly by noting all of your symptoms–including any and all phone calls where you discuss your symptoms (some doctors don’t keep notes of calls with their patients–losing very important information at times). If you doctor isn’t keeping proper records, it could mean longer wait time for a proper diagnosis–and treatment–which could even mean the difference between life and death or disability…

As far as Disability and the Social Security Administration, it doesn’t matter how disabled you are in real life–if it’s not on record and they can’t read how severely ill you truly are, you will not be approved for SSDI. The guidelines are very strict, and interpretation of these records depend on whether you’ll be approved for Social Security or not… Even if you have medical records as tall as you are… if your records don’t detail every symptom, official diagnosis, and the scale of your disability, you will lose YOUR money. Even worse, if you become disabled and still haven’t been diagnosed, you will have no chance at winning your “benefits” if you don’t get your answers before your DLI (Date Last Insured–The SSA’s term for the final day of being “insured”, ie. end of premium date). It doesn’t matter how many times you went to your doctor, or how hard you tried to get them to help you. Your relationship with your doctor, and how they keep record of your illness(es) will be the deciding factor in more ways than one.

Read more about why it’s so important for doctors to take proper records in the article Poor Documentation: Why It Happens & How To Fix It, and what can be done to help create change in the medical field.

It can mean more than just your life, it also means your quality of life/livelihood… Like you don’t have enough problems already, right?

 


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