Rosemary Makes a Medical Outline

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Art: Robin Mead

Everyone told Rosemary there was no way she would ever get approved. She had many things going against her:

She had no lawyer (no lawyer would take her case). She was young (age 32). Her main condition was Lyme (no Social Security policies recognizing Lyme). She was working part time (working while applying).

It gets worse! Her doctors records were all handwritten and nearly impossible to read. There was no way someone at Social Security was going to spend hours trying to decipher all these handwritten notes.

Rosemary Makes an Outline

Rosemary decided to make a medical outline to put all her medical evidence into a simple three-page list that could easily be read and understood.

Rosemary was not well enough to make an outline on her own, so her sister helped her. They collected all her records (hint: not visit summaries, not online records, complete records).

Then they went through her all her medical records, plus all her lab tests, plus any forms her doctor filled out. They looked for anything important. Because Social Security does not have any policies for Lyme, they looked for any evidence related to Chronic Fatigue Syndrome and Fibromyalgia.

Sometimes a three page document would only have one sentence that was relevant to her disability application. Then her sister typed up what they found. They tried to include at least one thing from every visit record to show the frequency of treatment.

Rosemary and her sister did not include any of their own writing, thoughts, opinions, research, or anything else that could cause Social Security to dismiss this document as merely the patient’s personal views. They used direct quotes from her medical records only.

What Happened?

After submitting her application, Rosemary’s sister faxed to her Disability Examiner:

  1. Medical Outline
  2. Copies of medical records and lab tests
  3. RFC form from doctor (handwritten and also difficult to read!)
  4. Letter from her employer detailing her significant limitations at work.

Afterwards, her sister called the examiner to double check that each document had been received and placed in her file. Two months later, Rosemary was approved.

Rosemary L’s Medical Summary

Below is a sample of ten months from Rosemary’s outline. The complete outline covered three years. More samples can be found here: How To Make a Medical Outline 


Patient Name: Rosemary L
Patient Social Security Number: 111-11-1111

10/20/2015 – Progress Notes – Dr. D

Medical Findings:
“Ongoing pain and disability due to chronic pain in muscles/joints”

Assessment:
“Fibromyalgia”


010/20/2015 – Laboratory Report – PL Medical Enterprises – Ordering Physician: Dr. D

EBV Acute Infection Antibodies
EBV Ab VCA, IgG – 396.0 (0.0-17.9 U/mL) H
EBV Early Antigen Ab, IgG 9.8 (0.0-8.9 U/mL) H


9/19/15 – Progress Notes – Dr. F

Medical findings:
“Neurological dysfunction”
“Mood disturbance – Night sweats with palpitation.”
“Significant cognitive dysfunction”
“Muscle and joint pain – Overwhelming continuous pain”

Functional impairments:
“Neurological dysfunction – Trouble balancing, imbalance while walking”
“Pain is aggravated by physical activity such as cleaning or shopping.”
“Can’t sustain physical activity. Unpredictable”.

Prognosis:
“Chronic fatigue syndrome, pain and fibromyalgia, plus severe cognitive and mood dysfunction make her unfit for employment.”

Diagnosis:
“Chronic Fatigue, Head & Body Pain, Encephalopathy, Cognitive Dysfunction”


9/19/2015– Residual Functional Capacity Form (RFC Form) Dr. F

Symptoms: Pain – severe – variable. Fatigue. Cognitive dysfunction.
Nature of the pain: “Dull. Shoulders, hips, legs”
Frequency of pain: “Daily”
Other factors: “Chronic inflammatory state. Chronic allergies”
“Prognosis is poor. Disability is not likely to change.”
“Pain – severe – variable – shoulder and hips or legs – can be constant and severe”
“Fatigue – some days incapacitated”
“Cognitive dysfunction – Loses concentration”
Ability to stand: “Variable – from not at all to few hours each day”
Ability to walk: “Variable – from ten feet to 4 blocks”
“Disability requires her to lie down during the day”
Difficulty performing motions: “Bending, squatting, kneeling, turning any parts of the body.”

Assessment:
“Chronic fatigue syndrome, Chronic pain, Encephalopathy”


5/12/2015 – Progress Notes – Dr. D

“Headaches every day. Pain through head, neck, shoulders, lower back, hips.”
“Depressed mood and affect”

Assessment:
Primary insomnia, Depression, Fibromyalgia


5/01/2015 – Statement of Health Status – Dr. F

Symptoms & Clinical Observations:
“Back pain, muscle pain, spasms, weakness and stiffness, jaw pain, neck pain and stiffness”
“Persistent swollen glands”
“Insomnia, visual disturbances, sound sensitivity, anxiety, irritability”
“Headaches, migraines”
“Poor balance”
“Cognition issues (short-term memory problems, confusion, difficulty with focus and concentration),
“Unrelenting fatigue.”

Health Status:
“Exacerbation of neurologic symptoms”
“Substantial cognitive impairment”
“Numerous primarily neurological and rheumatic abnormalities”
“Pattern of the current clinical and diagnostic findings is consistent with the diagnoses of Encephalopathy and Neuroborreliosis.”
“Chronic fatigue, headaches, migraines, dizziness and insomnia, the awareness of the intellectual impairment and stress from cognitive dysfunction further exacerbate her condition.”
“At least three chronic infections, caused by Borrelia, Babesia, and Bartonella”

Duration and progression:
“Persistent and steady deterioration of her medical condition without any significant improvement.”
“Identified and documented as progressively increased for consecutive 18 month period.”


4/10/2015 – Diagnostic / Clinical Evaluation – Dr. S

Diagnostic / Clinical Evaluation:
“Major Depressive Disorder.”

Functional Impairments:
“Continued negative impact in functioning due to her depression on a daily basis.”


3/06/2015 – Progress Notes – Dr. F

Medical Findings:
“Pain – down into shoulders almost daily”
“Joint pain – wrists, elbows, ankles”
“Muscle pain in upper half of body. Muscle tension and spasm in legs.”

Functional Impairments:
“Fatigue – required to lie down often to rest throughout the day. Unable to perform daily housekeeping and cooking.”
“Muddled and confused. Difficulty with conversation comprehension and word retrieval. Can’t sustain reading and short-term memory.”

Assessment: Chronic Fatigue, Lyme Disease, Encephalopathy


2/13/2015 – Progress Notes – Dr. D

“Shaking of body”
“Heart palpatations”
“Chronic fatigue/fibromyalgia symptoms”

Assessment: Anxiety, Fibromyalgia


12/4/2014 – Emergency Room Report, XYZ Hospital

HPI Neurologic Event.

MRI “Hypertensive T2, T1”

Diagnosis: Sleep disorder. Possible seizure disorder with vertiginous aspect.


Thanks for Reading

🌷 This page is part of the free online guide: The Sleepy Girl Guide to Social Security Disability 

🌷 Learn more about this topic here: How I Got Approved for Disability QUICKLY

🌷 Art on this page by Robin Mead and Elizabeth D’Angelo.

🌷 Page Updated: 8/1/19

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1 thought on “Rosemary Makes a Medical Outline”

  1. Thank you so much for this! I am having a friend go through your whole website because it is freakin amazing. I’m sure you hear all the time how incredible your contributions are to the disability community but this site is amazing and your work is freaking awesome and I can’t thank you enough!

    Like

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