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
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 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 I promise, it does get easier in time
🌷 Be Disabled
If you are too ill to work, one of the most important things (maybe the most important thing) you can do to help your case is get very comfortable admitting that you are disabled. Many people self-sabotage their cases because they are too shy to be clear with their doctor or to admit to Social Security (or admit to themselves) that they are now disabled.
🌷 Be Medical
If you talk to your doctor about working, discuss your medical condition and tell your doctor if there are medical reasons you cannot work. Tell your doctor if your symptoms keep you from being able to work. If you are having other kinds of problems (childcare, transportation, unemployment, bad economy, bad boss), you probably want to talk to a Social Worker, not a doctor. A doctor cannot help you with these things, and disability cannot approve you if these are your reasons for not working.
🌷 Be Consistent
Social Security looooves consistency. They will look to see that what you say to your doctor is the same as what you say to Social Security and the same as what you write on your forms. Learn more about How to Be Consistent
🌷 Be Upfront
Please tell your doctor about your disability application and ask if you have their support. This is so important. If your doctor is not supportive and your doctor does not believe you are disabled, you want to know as soon as possible, while there is still time.
🌷 Be On Topic
Many lawyers recommend not to chat about your life with your doctor. They suggest to focus on your symptoms, medical treatment and disabling condition. Sometimes small innocent remarks can be written down in a way that can be misunderstood. According to the attorney Scott Davis, topics that sometimes cause problems in medical records are: caring for pets, caring for children, participating in activities, traveling, and alcohol and drug use.
🌷 Use the Magic Words
If you are unsure how to answer a question, try using the magic words. The magic words are “When I am having severe symptoms….” 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. Don’t put on a good face and spend all your energy sitting up and talking and walking around the doctor’s office, and then go home and have a crash and spend the next week in bed. Let the doctor see what you are actually like. I love this article written by someone with CFS/ME and Lyme. Don’t Try to Look Good When You Feel Like Crap
🌷 Discuss Functioning
It is a great help if you can talk about functioning with your doctor and if notes on functioning are included in your records. Talk with your doctor about any limitations or difficulties you have with sitting, standing, walking, lifting, grasping, bending, thinking, focusing, concentrating or remembering. If side effects from medications make it difficult to function, please mention this as well.
🌷 Consider Your Records
Some doctors will write down everything you say in your records. Some doctors will scan in letters or papers that you hand them or email them. Some primary care doctors include short “mental status reports” in their notes. These may include if the patient is alert, oriented, bathed, clean, dressed appropriately, able to remember things, and able to hold a conversation. Some doctors will note if a patient uses medical equipment (wheelchairs, canes, walkers, etc) during the visit.
🌷 Find Out For Yourself
If you are not sure what your doctor is writing about you, there is only one way to find out: Collect your records and read them. Believe me when I tell you, you want to know now, not later. Having copies of your records may also help you if your doctor moves or the practice shuts down. Do not look at visit summaries, do not read your records online. You want your full records with complete treatment notes.
🌷 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.
🌷 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 having a different mindset, 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 do the best you can with it.
🌷 Updated May 2017. Please share questions, stories, ideas below. Please let me know if any links on this page are not working properly. 🌷