Part 2 of 5 - A Self-Help Guide: Applying For Social Security Disability Benefits By Janie M. Laubscher
Make Your Doctor A Part Of Your Team
SSDI benefits are awarded when objective medical evidence establishes that a condition or conditions are severe enough to prevent a person from working. Your treating physician is usually considered the best source of such evidence because he/she normally has an ongoing relationship with you and can provide evidence about your condition over a period of time.
Your Medical Reports
Often, your claim can be decided on the basis of your treating physician's report alone if it's timely, accurate and detailed enough to reduce or eliminate the need to obtain additional medical evidence. In my work:
Most fall somewhere in between. So, how can you help to ensure that your medical reports measure up? - communication.
Communication
Communicate with your doctor. Take a list of things you want to discuss to each appointment. You would want to do this in any event because feedback from you is useful, perhaps even vital, in determining your treatment. But at the same time, you are also helping to construct a history of your impairment for a possible disability claim. To that end, you need to do your part to get information into your chart because that's what your doctor will refer to in preparing a report.
The Nitty-Gritty Of Your Medical Report
Here's what a medical report for SSDI benefits should include:
- your medical history
- clinical findings
- laboratory findings
- diagnosis
- treatment prescribed, response, and prognosis
- an opinion about what you can still do in spite of your impairment(s)
- work-related difficulties
Below are some suggestions about how you can help your doctor to make your chart (and thereby his/her report) as complete and accurate as possible. The methods I'm suggesting would work no matter what condition you have. Bear with me if my examples are related to rheumatoid arthritis since that's what I'm most familiar with.
Your Medical History
This is an account of the course of your impairment over time. It includes clinical findings, treatment and response to treatment and your statements about symptoms such as:
- pain
- stiffness
- fatigue
At each visit, be sure to tell your doctor about your symptoms including:
- how bad
- how frequent
- what parts of your body are affected
- what makes them worse
- what relieves them
- how they affect your ability to function at work and at home (most important)
Clinical Findings
These are based on the doctor's examination of you, and they include such things as:
- descriptions of swollen, red or "hot" joints
- descriptions of limited motion of joints
- descriptions of deformities
- reports of elevated temperature or swollen glands
- observations of any difficulties with standing, walking or sitting
Make a point of showing your doctor any problem areas at each visit.
Laboratory Findings
These might include reports of:
- x-rays
- blood tests
- bone scans
- bone density studies
Whenever your doctor orders a test for you, he/she gets the results, and they are filed in your chart. Whenever you've had tests always ask your doctor about the results. You're interested. And make sure those test results are in your chart.
Diagnosis
Whatever your diagnosis, make sure any tests that helped your doctor to make it or that confirmed it are in your chart. For example, a diagnosis of rheumatoid arthritis (RA) is, in most if not all cases, corroborated by blood tests. Remember the "disability listings"? A finding of disability under the listings requires one of the following: a positive test for rheumatoid factor or antinuclear antibodies or an elevated sedimentation rate (sed rate). If you have a diagnosis of RA, you've probably had one or more of these tests. Make sure the results are in your chart.
Treatment Prescribed / Response / Prognosis
You have a lot of "inside information" on how your treatment is working. Let your doctor know if medications are not working or if you're having side effects from them. And let him/her know how these problems affect your ability to function.
