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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What Most Doctors Don’t Know About Social Security Disability – And The SSA Doesn’t Tell You!

I had a follow-up doctor’s appointment a while back. I told him about the last two months health-wise, and brought him up-to-date with my most recent Social Security Disability Hearing and told him that it probably wasn’t looking good for me… Again. As usual, he couldn’t understand why I was still fighting; and then we continued on with my appointment.

doctor-patient-consultation

I was about to leave the room and something popped up in my head (I love how my brain works now). I stopped, and asked him if he ‘knew of a form I read about online that Social Security apparently wants from doctors. That for some (ridiculous) reason, the SSA doesn’t really give too much weight to short letters written from the doctor; but this “Residual Functioning Capacity” form (linked below) is pretty important… Apparently, it can be the deciding factor in some cases?’

I don’t think my brain said it as eloquently when I spoke, but luckily he understands me–even when I babble and slur.

It turned out though, that he didn’t really know anything about this form (he ‘thinks he heard of it’, he claimed, but asked me to send him a copy)! I can’t blame him for not really knowing about it honestly. A doctor’s word should matter to the courts when it comes to treating and supporting his or her patient–and Social Security should use any records or letters put into evidence, as long as they detail the diagnoses and note whether or not they consider the patient permanently disabled.

But if a doctor’s letter doesn’t entirely count as far as the SSA is concerned, why hasn’t this practice been changed?

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What concerns me is how many doctors don’t seem to know about this form (or how to file for Disability). They believe Social Security should take their word as gold that their patient is permanently disabled. But Social Security is basically stating, ‘Your letter and word as a physician isn’t enough, we want you to fill out an eight page form explaining, in detail, what their disability entails’.

With today’s technology, why can’t someone contact the doctor if they have any further questions (beyond the medical records)? Wouldn’t it be better to have a more personal account of a patient rather than make them fill out a detailed, “Can your patient lift 5/10/20 pounds on a regular basis – if so/not, please explain” form.

Instead, everyone’s fate rests on the hand of the SSA’s expert medical witness’ testimony (whom may or may not specialize in your illness(es)) by reading only the doctor’s notes–yet not hearing from the patient themselves. Therefore, they are basing their opinions on medical records that may or may not be detailed and complete.

Can you imagine the scores of people that keep getting denied Social Security and are constantly struggling, becoming homeless, and even dying because this ONE FORM wasn’t filled out by doctors–most likely because they didn’t know that it existed in the first place? (Note: When I tried finding it through the Social Security Website, I kept getting a “404 Error” message every time I tried to reach the page – It does exist though – see below for the link!).

PLEASE, everyone, SHARE this page! Tell your friends that are fighting, or about to start their fight, for their Disability benefits to print out the RFC form linked below–and make sure your doctor gets a copy. Have them share it with their colleagues!

Help stop this insanity!
PH

There’s so much I would have loved to have known when I became ill enough to be ultimately forced to apply for Disability. I truly hope that this helps someone so they don’t have to go through what I have… and still am because of poor medical treatment and recordkeeping.

I eventually began searching online, rather than the SSA website for the form, and finally found a copy that can be printed out HERE (pdf version). I’m hoping that doctors will start hearing more about the RFC form–and start helping their patients with disabilities win their Disability fight in a timely manner by filling it out.

I’m hoping even more that Social Security catch up to the times and realize that today’s doctors aren’t old school like Social Security still is (Come on, the system has barely changed since 1935–Over eighty years!). Doctors just don’t have time with the amount of patients they have to take care of today to fill out eight-page reports. Detailed notes (including via telephone) and detailed record keeping should be able to properly show a patient’s health status without question; while a patient’s testimony should be taken strongly into consideration–especially if a case lasts longer than five years.

No one should have to wait more than five years for their benefits.

Both the Social Security System and the medical industry need to create a simpler system that both can work with, so people that are truly disabled get their benefits in a more timely, and less stressful manner.

It is our money after all.

Until the laws get changed though, get that RFC form to your doctor’s office and ask them to fill it out along with your Disability application.

Good luck!!!

In case you missed it, click the link for access to the SSA’s RFC form: https://secure.ssa.gov/apps10/poms/images/SSA4/G-SSA-4734-U8-1.pdf

Guilty Until Proven Innocent

UPDATE 12/2/16: My attorney dropped me with only two weeks before the deadline to file in Federal Court. We’re scrambling to find an attorney willing to take my case because of the state of limbo I am currently in. There’s a good chance I’m going to lose everything because of this. I haven’t given up, I just need to regroup and come up with a plan–quickly. Prayers are desperately needed.

UPDATE 10/28/16. Denied yet again by an ALJ. Appealed and SSA sided with the judge. Now I have to file a civil suit in Federal Court (again) to either have it remanded back to the SSA, overrule or (heaven forbid) side with the denial. The SSA still doesn’t know anything other than what they see on paper – and won’t seem to connect the difference between my past medical records and current ones – even though the symptoms have only worsened, never contradicted.

UPDATE 5/28/16: The decision for my Disability hearing came in, and I was denied again. I wasn’t surprised at all, albeit a bit let down. Of course, I appealed again.

Come back and visit to find out any future updates for my continuing fight for Disability.

2016 marks ten years since I first filed for Social Security Disability. I wish I could say that I’m the only one going through this fight that I never expected nor wanted to be in, but unfortunately I can’t. Too many people have gone broke, homeless and even died during their fight for their income… Too many others just give up the fight altogether, their lives ultimately ruined.

How incredibly insane is that? To have to fight so hard for something that you paid into your entire working life, only to be told “No”, over and over again when you need it the most!

I had my (technically) fourth hearing in front of an administrative law judgeSSDC-Denied.png a few weeks ago, and if I were a betting woman, I’d say my chances are pretty slim on being approved.

Again.

I’m hoping there’s a saving grace after that fiasco of a hearing… A last minute letter that my lawyer wrote to the judge pleading in my favor. Also, I recently went to the DMV and got a receipt that proved that I received a Permanent Disability Placard as early as August 2005 (they’d have to go to archives to get any older information). Some months before my alleged *Disability Date, and **Date Last Insured (DLI). A very nice representative there even signed and stamped it to make it as official as possible to try to help me <3.

I’m hoping that the above will help the judge realize that I was already considered disabled by my then-doctor, way before my listed Disability Date on my application.

Guilty until proven innocent. That’s what it feels like for me to fight my Social Security case. I think what offends me most is that the SSAguiltyinnocent thinks they know better about my disability (and inability to work) than my doctors and me. My last judge even observed an old manicure (that I had gotten with my daughter for her 16th birthday – my first in a couple of years), and it influenced his decision that I wasn’t depressed enough.

I can’t afford my own medical experts, because I haven’t worked since 2005 ($500+/hr is a little steep for a family with one income in California). Still, I don’t understand why I should even have to hire experts when I have letters from FIVE doctors, stating that I’m permanently disabled for one reason or another.

The most important letter in my mind though, was from an ex-doctor I had during the time in question (my Disability Date). I forced myself to call him a while back, after yet another denial from the judge. I explained to him that I finally got my diagnoses (of Multiple Sclerosis and Lupus and more) after leaving his office and the medical group. Then I mustered the nerve and asked him to write a letter to the judge on my behalf, and tell them whether or not he considered me disabled during that period. He agreed (even though the letter was pretty vague, he did tell the SSA that he considered me permanently disabled during the time in question).

Side Note: If you read about the history we had in the past, that was not an easy phone call for either of us to go through. But man, it felt so good for me to let him know that it wasn’t all in my head like he and his colleagues kept trying to push on me for so long! (To read more about that, go to Chronic Hell: My Story).

If you have never applied for Social Security (I truly hope you don’t have to until you retire), don’t get too cocky and think you’re going to win right away. I’m sorry, but it’s true. It just doesn’t happen as easily as that very often at all. Very few doctors know how to word their records for the SSA to easily determine Disability (If it did happen that way for you, congratulations! You are definitely one of the lucky few!).

Fraud-in-Dictionary.jpgI hear that the first few denials are to “weed out” the fraudulent cases. It takes months, even years to go through the appeal process after you do get denied; and then just as long to repeat it all over again. It’s a truly vicious process.

This all, of course, is also supposed to weed out those “frauds”.

I keep wondering how long you have to fight to prove that you aren’t a fraud. I’m really hoping ten (years) is my lucky number. I’m not getting any younger, and definitely not getting any healthier.

Even though I have a mountain of records that show that I had symptoms of all of my current diagnoses way before I became disabled; I had no big, “Hey, she’s a winner!” official diagnosis before my DLI that wowed the Social Security Administration enough to approve my application… Or so they try to claim (my first denial was because their examiner said I had a “social life” – I went to a few music concerts and high school football games, both seasonal at best).

Because my (ex)doctors didn’t really look too hard for what was wrong with me back then (and kept horrible records), their favorite go-to diagnosis for me was Depression. Man, that word ticked me off every time I heard one of them go back to that! Rather than actually take a test to see what was really going on with my actual symptoms, they kept referring to Depression. It’s the one big thing that I had back then that was documented enough to keep my case open though, so I have to keep hearing it.

Am I depressed?girl-1098611_960_720.jpg Of course I am (especially after dealing with so many bad apples in the medical profession, and of course, my fight with the SSA)! So many scary symptoms were happening to me that were basically ignored by my ex-doctors back then; and at home everything was getting turned upside down. No matter how many people were around me, I felt so alone; scared.

Even while I was sick with a case of Meningitis in the hospital in 2005, they still kept pushing Depression. Apparently, it didn’t help that I fired my doctor from my hospital bed. I guess you’re not allowed to make big decisions like that when you’re sick. If I was a litigious person, I would have sued them all for malpractice – Sometimes, I wish I would have.

All I ever wanted was to feel better again so I could get back to my life… I actually loved my work. I really miss running my own company, being my own boss – Something I worked really hard to become until my illness took it all away.

Most of all, I miss me.

I can only hope that this new judge can see through all the craziness in the form of my case (including the comments made to me by the last judge – I’m SO glad he retired last year!), and realize that there is so much more to this picture than there is on paper. I also hope that she’s compassionate enough to finally stop this part of my roller coaster ride.

I’ll find out the answer in about a month. Fingers crossed.


*Disability Date – The last day of actual work.
**Date Last Insured – The “date last insured” (DLI) is the last date that an individual is eligible to receive Social Security Disability Insurance (SSDI). In order to receive SSDI, an individual must pass the “recent work” test. (from Google Search)

 

Doctor Writes A Letter To Patients With A Chronic Illness

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Why aren’t Medical Schools teaching a class on Doctor/Patient relationships and the insecurities and communications (and miscommunications) that happen between them?

I know it would have been a much more pleasant experience for me all those years, if a doctor would have had the guts to just say, “I’m sorry… I can’t help you. Please find a new doctor.”

It would have been so much easier than their favorite go-to, “Go see a psychiatrist”.

After the scores of “insecure” doctors I have been to over the years, I think I just might, thank you.

Click to read the letter, “A Letter To Patients With Chronic Disease“, by Dr. Rob Lamberts in his blog. He actually sounds like he gets it!

Why Doctors Need Two Left Shoes

legs1After years of serious and thoughtful observation (i.e. doctor visits, hospital stays, and conversations with other patients), I have come to a conclusion. I believe medical professionals should be required to wear two left shoes at work for one day.

Why, you ask? Well, I’ll tell you my theory…

Living with a chronic illness, we go through symptoms that healthy people never usually experience. Because of this, we quietly wish healthy people were able to understand what it’s like to be sick 24/7/365 (including leap year—we don’t get that day off either).

Of course, we would never ever wish our pain on another person—we know too well what it’s like to hurt all the time; to be constantly sick… we wouldn’t dare wish any of this on our worst enemy.

Empathy is a wonderful thing… To have the ability to “understand” what someone is  going through, you can appreciate better what pain can be like—and therefore, treat us better.

That’s why I figure if people in the medical profession wore two left shoes for just one day, they will quickly be taught what it’s like to live (and work) in pain—and hopefully consider their patient’s pain and symptoms/complaints more thoughtfully in the future.

If they ever needed a refresher course? They can wear two left shoes with tiny pebbles added for an extra reminder! What a lesson that would be… Ouch!

It would be a simple, yet effective experiment… don’t you agree?

Wouldn’t it be great to suddenly start seeing people in the medical profession wearing two left shoes?

I’m just sayin’!