What You Tell Your Doctor Matters to Your Social Security Disability Case

patient talking to doctor who is taking notesWe constantly tell our clients that getting medical treatment is a key factor in winning a Social Security disability claim. 

Possibly the next most important factor is what your doctor’s treatment notes say about your condition. Your claim will be strengthened when your doctor’s notes are consistent, when they are focused, and when they support the rest of your Social Security disability application.

Why Consistency Is Important

Some cases are won because the individual consistently made the same complaints to his doctor. I can think of several cases we won because the individual made an effort to consistently complain to the doctor about one, two, or three specific ailments during every visit to the doctor.

For example, if your disabling condition is headaches, you should talk to your doctor about the headaches at every visit. Then, your doctor’s notes should mention frequency, duration, effectiveness of medications, related symptoms (for example, nausea, vomiting, light or sound sensitivity, etc.), or your need to lie down during a severe headache.

When a judge reviews the treatment records, he or she may be persuaded that the headaches are a severe and disabling condition because the headaches are consistently mentioned in the doctor’s treatment notes.

Having Focused Complaints Is Also Important

Sometimes I review medical records and the client will have complained about a cold. The next visit it was abdominal pain. The third visit was for burning feet and hands. Then dizziness was complained about at the last visit. In such a case, the judge may not understand exactly why you are disabled.

Unless the key impairment is reflected in writing in your doctor’s treatment notes, it is as if the problem was never discussed. The nurse or doctor needs to write your key complaints in the treatment notes at every visit, but first you must mention your specific complaints at each visit.

Your doctor is important to your Social Security disability application, and these simple tips could help strengthen the medical records that support your Social Security disability claim.

John Driskill
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Board Certified Houston Social Security Disability Lawyer
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