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What Is Your Doctor Writing in Your Medical Records?

Knowing and Understanding What's in Your Medical Records and Undertanding and Remembering What Your Doctor Told You


The medical profession has made great strides in how it communicates with their patients. Likewise the past twenty years has given people more and easier access to their medical information. When looking at records I often find myself telling clients things that they say they never heard. I am not a doctor so I have to be careful what I tell them at the same time I need to build a case. Often I will ask them, "What did you doctor say about X." This will be on something fairly basic. They will answer that they don't know or are unsure. Various socio-economic factors often come into play so it's not neccessarily the fault of the doctor. Once I had a client who forgot just a few days later that he wwas advised to get spinal surgery! Often I see people in severe pain or expressing severe mental illness symptoms. Parts of the record indicate they are an opiod addict. This is despite there being nothing else in their records for years that would indicate that was the case. I tell my client's about words in their records such as "mild," "good" and "progressing nicely." Subjective phrases such as these that are not attached to specific limitations or the frequency, intensity,and duration of symptoms have been somewhat a source of contention in the federal courts. The courts have generally ruled that these phrases should not be used by Social Security to make a decision. Quantifiable measurements are what are most important. Some follow this sound logic in Social Security and some do not. If they don't, guess what percentage of cases make it to federal court? Not a lot. The article below brings up some interesting issues related to all this.


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