I thought I always read all my medical records. I read everything they gave me after every appointment. When I got the disability decision from the judge, I was shocked. It was full of quotes from my doctor that I had never seen before. – Ivy
Am I Getting My Full Records?
Many patients think that they are reading their full records when really they are just reading visit summaries or online records. Ask yourself these questions:
🌟 Did I sign a form requesting my records?
🌟 Did I pay money for them to give me my records?
If the answer is no or no, you may not have not seen your full medical records.
TEN COMMON THINGS THAT APPEAR IN RECORDS
🌟 Some doctors include “mental status reports” in their notes. These may include if the patient is alert, oriented, able to remember things, and able to hold a conversation.
🌟 Some doctors will write about what you are wearing and if you are bathed and appear groomed.
🌟 Some doctors will note if a patient uses medical equipment (wheelchairs, canes, walkers, etc) during the visit, and will note observations about how you walk, sit or stand.
🌟 Many doctors will observe a patient and write down their observations. These observations can be much more important than what you say to your doctor.
🌟 Some doctors will write down things a patient says, including personal information, stories the person tells, family information, and life activities.
🌟 Some doctors will scan in letters or papers that you hand them or email them.
🌟 Some doctors will write their opinion about whether you are following treatment. For example, when a patient stops taking meds, one doctor might write “Discontinued medication due to severe side effects” and another doctor might write “non-compliant with medication.” There is a very big difference between these two things.
🌟 Some doctor’s will say one thing to you, but write down something completely different.
🌟 Some doctor’s will take very few notes, and will not include any of the important information about your symptoms and limitations in their records.
🌟 Some doctor’s offices have computers that auto-fill background information into the treatment notes. This means if something is incorrect in the auto-fill information, it will keep being incorrect on every single record from every single visit, until you discover and fix it.
The only way to know what your doctor is including in your records is to request all treatment notes and read them yourself. Having copies of your records may also help you if your doctor moves or the practice shuts down.
I cannot stress this enough: YOU MUST READ YOUR RECORDS. My doctor always told me that he believed I was disabled and he understood how much I struggled. Then I read my records.
Over and over, he had written that I “alleged” pain but my demeanor was happy and joking so the pain must be mild. He wrote that I was exaggerating symptoms. I do try to stay positive through pain. I never imagined my doctor would write that.
This is absolutely true! I am a paralegal and have worked on cases for personal injury paralegal, Workers’ Compensation, Social Security and state retirement disability.
Your full medical records are so much more extensive than the sometimes worthless summaries they hand you, or make available on the patient portal of their website.
Complete records will also include differential diagnoses (a list of what MIGHT be wrong), information on drug and alcohol use, lab results, treatment plans and much, much more.
The most disheartening content of the complete records can be errors and misstatements. I have seen so many medical reports that are blatantly wrong, and ultimately harmful to a person’s lawsuit or disability claim.
Another reason to get copies of your records is that doctors can purge their records after a certain number of years, so previous records could be lost forever. Those past records can help establish a decline in health, changes in physical and mental abilities, and other diagnoses that you have.
We are all our own best advocate when it comes to our health and well being! You have a right to get copies of your records.
– From Darlene McKee Flynn
My doctor wrote that I was neat and clean and well-dressed and well-groomed and alert and oriented. I don’t know how he even wrote that when I was hysterically crying and barely functioning half the time.
The judge’s denial said that my records were inconsistent. Even though my psychologist had really good accurate records showing I was disabled, the judge disregarded this, because of what my doctor wrote. – Ivy
Updated April 2018. Please comment below with stories, ideas, questions or suggestions. Please let us know if any links on this page stop working. If you found this page helpful, please share it with others by pressing one of these magic little buttons: