Carnation’s Doctor Takes Terrible Notes

Art: Robin Mead

When Carnation collected her medical records, she realized she had a very big problem.

Her doctor took terrible notes and very little information appeared in her medical records. Although her diagnosis was listed, there was little or no information about the details of her symptoms, level of severity, or how this impacted her ability to sit, stand, walk, lift and function.

Luckily, Carnation figured out a way to solve this problem.

STEP ONE: CARNATION USES AN RFC FORM

Carnation started by asking her doctor to fill out an RFC Function form for her. Her doctor agreed, and this form was a huge help. Here’s where you can learn more about How to Get a Great RFC Function Form

Even though the RFC form was great, as Carnation learned more about the disability process, she realized this would not be enough. Social Security wants to see a record of your impairments at every visit, not just one time.

STEP TWO: CARNATION MAKES HER OWN FORM

Carnation decided to create a short one-page assessment form and began bringing this with her to every doctor’s visit. Her assessment form was based on these longer: Sample Residual Functional Capacity Forms

At the beginning of each visit, she brought a copy of the form asked her doctor to take five minutes to fill out and sign this brief form. Many doctors do not like disability paperwork, but since this was a very short form he filled out during the office visit, he was happy to do it.

Now every single visit had strong a record of her symptoms, impairments, and functional limitations written by the doctor.

STEP THREE: PREPARING A MEDICAL OUTLINE 

Before her hearing, Carnation collected together all the forms her doctor had filled out, plus her other medical records. She went through everything and put together a medical outline of what appeared in her records.

Tip From Carnation: Carnation wanted to make sure that Social Security did not dismiss her outline as her personal opinion, so she left out all of her own writing. She didn’t include any of her thoughts, opinions, or research. She used direct quotes from her medical records only.

Learn more about making a medical outline How To Make a Medical Outline to Help Your Disability Case

PROBLEM SOLVED!

Carnation’s outline was so good, the judge praised it, and then included the entire outline right in his decision letter! Carnation was awarded a fully-favorable approval.

Below is a copy of the first few entries in her outline. (The complete outline went back several years.) Carnation was kind enough to share parts of her outline to help others:

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CARNATION’S MEDICAL OUTLINE

3/20/2015 Office Visit. Provider: Dr. J

Patient states she is having pains in her hands, fingers, hips, shoulders. She is having headaches everyday. She reports she still has lost focus and drive to do anything

• Patient has decreased range of motion range of motion in her hands and fingers
• She has pain in hands and fingers that get worse throughout the day the more she uses them
• She is unable to do typing and dialing due to paresthesia, numbness, and pain in her hands fingers and shoulders.
• She is unable to stand or sit for long periods due to hip pain.
• she also can not do her job due to depression
• Still having problems with focus, memory, and concentration.
• Still having recurrent headaches
  

Physical exam:

• Lower back, neck pain
• Back pain in low back, very tight, pain with any rotation, flexion, and extension neck pain-limited ROM secondary to pain and stiffness turning right to left tender in neck mild with extension
• Extremities: patient is experiencing decreased range of motion.
• Edema noted
• Patients ROM decrease in hands and fingers secondary to pain and stiffness.
• The pain and stiffness gets worse with activity

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4/30/2015 Office visit Provider: Dr. J

Chief Complaint

• Headaches Hands/Hips Are Hurting,
• Legs are going numb
  

Review of systems

• Fatigue noted
• Malaise notes
• Nausea noted
• Diarrhea noted
• Back pain noted
• Neck pain noted
• Myalgia noted
• Stiffness noted
• Weakness noted
• headaches noted
• numbness noted
  
• paresthesias noted
  
• chronic pain noted
  
• depression noted
  
• Lower back,neck pain
  
• Back pain in low back,very tight,pain with any rotation,flexion, and extension neck pain-limited ROM secondary to pain and stiffness turning right to left tender in neck mild with extension
  

Comments

• “Patient has FIBROMYALGIA which causes abnormal sensations or NUMBNESS with WIDESPREAD MUSCLE PAIN.”
  
• “At this time Patient is unable to sit or stand for any length of time and has trouble with her computer work.”
  
• “Fibromyalgia is also affecting her sleeping causing insomnia and she has become depressed. Advised to take zoloft for depression and follow up with other specialist so she can resume necessary medications.”
  
• “Symptoms can make it difficult to concentrate and perform the functions of her employment”

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MRI 11/24/2015

Reason for MRI

• Migraine headaches, leg numbness and non traumatic posterior neck pain.

Findings

• Small white matter lesions involving frontal lobes are non specific and likely represent gliosis. White matter lesions have been reported in patients with chronic migraine headaches.

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4/27/2015 Office visit Provider: Dr.S

Chief Complaint

• follow up on fms, oa, and hrm

History of illness

• She is here to establish care for further evaluation of pain and stiffness in her joints. Has history of fibromyalgia and osteoarthritis She feels overall symptoms have gotten worse in the last several months Sometimes she gets only one hour of rest a night, others she can sleep 2 or so. she also notes swelling over her hands and feet Review of systems Positive Headache Positive Joint pain, joint swelling Positive fatigue

Physical Exam

• Pain over several fibromyalgia tender points bilaterally, soft tissue discomfort noted posterior neck, left posterior shoulder,right posterior shoulder,right chest,left chest,upper back,lower back,left posterior thigh,right posterior thigh,right knee,left knee.
• There are 14 out of 18 total tender points

Assessment

• Polyarthralgia
• Myalgia / patient presents with pain and stiffness in several joints

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