We constantly tell our clients that getting medical treatment is a key factor in winning a 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 with your court testimony.
Consistency is important. Some cases are won because the individual consistently made the same complaints to his or her 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 complaints during every visit to the doctor.
For example, if your disabling condition is headaches, you should complain to your doctor every visit about the headaches. 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 the headaches are a severe and disabling condition because they 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.
If you are seeking disability due to diabetic neuropathy, those complaints must be seen many times in your medical records. Even when you are in the midst of a cold and go to see your doctor, you can still discuss how neuropathy affects your ability to perform small tasks around the house. If you can’t peel more than two potatoes due to burning in your hands you must tell your doctor. If it hurts to grip a steering wheel you must tell your doctor. Even if you see your doctor about dizziness, you can still take that opportunity to discuss some aspect of your neuropathy and how it impacts your daily activities.
Finally, 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!