Building Your Case with Medical Evidence



Building Your Case with Medical Evidence

The Social Security disability process is an interactive process between you, your representative, and the Social Security Administration. Hiring a Social Security disability representative is a step in the right direction, however, there are key things only you can do.

Your participation in your case is critical and you have more power than you may think.

The number one thing you have the most power over is your medical records.

If someone owed you money and you were going to sue them, do you think a Judge would order that person to pay you money just because you said so? Probably not. You would have to come to court with some kind of proof, like a contract, or a receipt, or a copy of a check.

The same thing applies to your disability case. It is highly unlikely that Social Security will approve your claim just because you tell them you cannot work. You must have some kind of evidence.

The evidence in a Social Security case is medical records. Approving your case will be difficult without medical records; and just like in any other legal case, the quality of your evidence makes a huge difference.

There are 2 types of medical evidence: objective & subjective.

Objective evidence is the record of signs, deficits, or impairments that can be observed and described or measured. These are physical findings where a doctor does not have to rely on your cooperation or report. Examples include diagnostic test results, such as a MRI, EEG, lab results, and observations of function.

Subjective evidence is anything else that cannot be observed or measured through testing. Your symptoms and complaints of pain, weakness, fatigue, side effects of medications, your report of your inability to do certain activities; these are all subjective.

Let us take the following example:
· You are complaining of severe back pain (subjective); and
· Your MRI says you have a slight or mild disc bulge or (objective); and/or
· You are not taking any substantial pain medication (objective); and/or
· You are not seeing a doctor.

Social Security and private representatives analyze whether or not the subjective evidence (complaints of pain), could reasonably be produced by the impairment. (by looking at the results of the MRI (must be moderate or severe) or the medication you are taking.)
In this example, Social Security will probably find your subjective complaints of pain do not match the objective evidence. (mild MRI results, little pain medication, no medical care) In addition, people who are in severe pain generally will do anything to find relief.

Your doctor can create objective evidence by requesting the appropriate tests, which will diagnose your particular impairment.

Subjective evidence is a little more difficult. This is when the disconnection happens – the difference between what you tell your doctor and what actually ends up in your medical records. What you tell your doctor may end up as notes copied and pasted from the last visit, as the phrase “no new complaints”; or even worse, notes in the doctor’s scribbled handwriting, which no one else can read!

The consistency of your complaints is part of the way your credibility is determined. Credibility is whether someone believes your subjective complaints. It is important to get your subjective complaints documented in the record. Can you imagine showing up to court and telling a judge about all your complaints, but when the judge looks at your medical records, he does not find any of these complaints in the records!?

It is important for your subjective complaints to match the objective evidence. Do not exaggerate or minimize your problems. If you are disabled, exaggerating is not necessary; and if you do, Social Security will not believe anything you say. It is likely to be fatal to your case if a doctor writes in your record that you are exaggerating or malingering. On the other hand, don’t tell the doctor you are “fine” if you really are not.

The next time you have a doctor’s appointment, it is your job to make your doctor understands you need your complaints put in the record, EVERY COMPLAINT, EVERY TIME. You should request a review of your medical chart; and if you can’t read your doctor’s handwriting, neither can Social Security.

Your medical records are one of the most important pieces of your case. It is your responsibility to ensure your records are the best they can possibly be with the resources available to you.

Other Things You Can do to Support Your Claim Through Medical Records
Get current medical treatment. Contact us for referrals to community resources.
Every time you go to the doctor report ALL of your symptoms, consistently. Do not tell the doctor you are “fine”, unless you really are.
Follow through with referrals and testing.
Emergency room visits do not take the place of a regular doctor.
Multiple emergency room visits to get regular pain medication is also not good for your case. (but you should seek emergency care if you are experiencing breakthrough pain or any other impairment crisis)
If you go to the hospital, stay until you are released. (don’t leave against medical advice)
Be honest. Don’t exaggerate or minimize your symptoms. Social Security takes everything very literally. (e.g. Don’t say you can only sit for “a few seconds” – state the actual time you can sit.)
Take your medications as prescribed. If you take more than prescribed it is not good for you or your case.
Do not stop taking your medication, or you will be considered “non-compliant” & you could be denied!
If you have depression and need, or are on anti-depressants, it will help your case if you see a psychiatrist.

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