How to Have Doctor Visits That Create Accurate Records

Robin Mead

When you are in your doctor’s office, and your doctor is writing notes, your doctor may be thinking about all kinds of things.

Your doctor may be thinking about your treatment and your health and the medical tests and the prescriptions and other patients and maybe what’s for lunch and how cute the nurse is.

Your doctor may not be thinking about your disability case.

That is OK. Your doctor doesn’t have to be thinking about your disability case… because you will be!

Here’s a whole bunch or ways to have great doctor visits that will help your records be accurate.

🌷 Be Honest With Your Doc

It is important to be honest with your doctor about your symptoms. It is important not to lie or exaggerate your symptoms… and it is equally important not to understate or hide your symptoms! As Mark Twain says, “If you tell the truth, you don’t have to remember anything.”

🌷 Be Honest With Yourself

This is one of the biggest ways people sabotage their disability cases. They are not ready to admit/accept how disabled they are, and they give their doctor mixed messages, or say things to give the impression they might be able to go back to work, even when there is no realistic possibility they will be able to manage this. This can lead to confusing or inconsistent things being written in their records that can cause major problems.

🌷 Be Embarrassing

It’s not easy to tell your doctor embarrassing things. If you need help to walk, eat, bathe or go to the bathroom, it’s really important to share this with your doctor. It’s hard to say at first, but we promise, it does get easier in time

🌷 Be Guilt-Free

Some people feel guilty always showing up with bad news at their doctor’s office. They want to be nice to their doctor and tell their doctor how much the treatments are helping. Please tell your doctor the truth. Don’t say something that is not true just to be polite.

🌷 Be Repetitive

Try to discuss your limitations and severe symptoms every time you see your doctor. Don’t worry if you have said it already a million times. Say it a million and one.

🌷 Be On Topic

Some disability lawyers recommend staying on topic while at the doctors, and talking about your health problems and your symptoms. Learn more about statements that cause problems in medical records.

🌷 Learn from Dahlia

Please take a moment to read Dahlia’s really great story that will help you understand way more about why all of this is important and how it might affect your records: Dahlia Finds a Surprise in Her Medical Records

🌷 Use the Magic Words

If you are unsure how to answer a question, many disability lawyers recommend to try using the magic words. The magic words are “When I am having severe symptoms….” Roselyn used the magic words when applying for paratransit: How Roselyn Used the Magic Words

🌷 Be Yourself

Act the way you act on a typical day. Dress the way you dress on a typical day. Talk the way you talk on a typical day. Let the doctor see what you are actually like. Here’s a great article written by someone with CFS/ME and Lyme. Don’t Try to Look Good When You Feel Like Crap

🌷 One Good Day is One Good Day

If you are having a good day, that is great! But before you go to your doctor and say “I’m feeling better” make sure you really are feeling better and your condition really has improved. Don’t say it just because you had one good day or one good week.

🌷 Be Realistic

It’s great to practice positive thinking. It’s a great to visualize yourself healthy again, and to believe that that is happening. But don’t do that visualization in the doctor’s office. Tell your doctor what is actually true, not what you wish were true.

🌷 Be Out of the Box

Some people were raised to believe that it is better never to complain. It is better to “grin and bear it” and remember other people have it worse. If you are applying for disability, please try your best to talk openly about your struggles. You may need to step way outside of your comfort zone, and be very strong and courageous to make this change

🌷 Be Willing to Change How You See Yourself

If you are too ill to work, one of the most important things you can do to help your case is get comfortable acknowledging to yourself that you are now disabled.  Being able to acknowledge this within yourself may change the way you talk and write about yourself with your doctors and with Social Security.

🌷 Be Informed

Many people have no idea the kinds of things doctor’s write in their notes. Please do not read your records online, and do not read visit summaries. You will need to request and collect full treatment notes to understand what your doctor is writing about. It may surprise you! What is My Doctor Writing About Me?

🌷 Don’t Hide Your Physical Struggles

Do not put on your best face while at the doctor! Do not hide your struggles or hide when you are in pain. Your doctor will write about what you say and also what you do while in her office. Your doctor might write about how you look, if you are able to dress and bath yourself, if you can sit up and carry on a conversation, if you can walk, if you have problems sitting, standing, walking, lifting, grasping, bending, thinking, focusing, concentrating or remembering.

🌷 Don’t Hide Your Mental Health Struggles

If you are having mental health struggles, please don’t hide this from your doctor. Here’s how Acacia Got Approved because of mental health symptoms her doctors observed. She wanted to share her story to help others.

🌷Talk About Side Effects

If side effects from medications make it difficult to function, this is a good thing to talk about as well. You can also collect your records to see what your doctor has written about this.

🌷 Follow Doctor’s Orders

Social Security will be looking to see that you are seeing your doctor regularly and following their treatment suggestions. There are a few exceptions. Learn more: How to Please the Social Security Gods

🌷 Double Check

The best doctor visits in the world will not help at all if they are not accurately recorded in your records. Many are completely shocked the first time they read their records. You may be surprised to discover the kinds of things your doctor writes about. Important: Please do not read visit summaries and do not read records online. You want full records with treatment notes.

🌷 Don’t Be Perfect!

You do not have to do everything on this page every visit. That would be impossible! This list is mostly about being honest about your symptoms, and keeping your disability in mind while you visit your doctor. You do not need to have perfect visits. Just try your best to be honest with your doc (and with yourself).

Learn More

🌷 Great Tips from Readers on How to Have Good Doctor Visits

🌷 How to Work with Your Doctor to Get Great Disability Documentation

🌷 Updated Oct 2017. Please share questions, stories, ideas below. Please let us know if any links on this page are not working properly. 

2 thoughts on “How to Have Doctor Visits That Create Accurate Records”

  1. I’m so glad you have this page. You have covered everything that I’ve been through along with how I feel. Thank You.


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