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As a therapist, doctor, or social worker your goal is to help your patient. You want to make things better. You want the medical treatment you administer or the counseling you provide to make a positive difference in your patient’s life so that your patient’s life can be as close as possible to what it was before he became sick or injured.

Sometimes You Can’t Make It Better

Sometimes your patient’s condition is permanent or terminal. Your patient will not be able to work for at least a year—if at all. While you can’t make your patient better, you are an essential part of your patient’s life. You may be able to make him comfortable and provide him with some peace during this very difficult time.

And You May be an Important Part of the Social Security Disability Eligibility Process

Your clinical notes should, of course, always reflect the truth about your patient’s condition. However, it is important to know that if your patient is terminally ill or permanently disabled that your office notes may be an important part of the Social Security disability eligibility process. Accordingly, it is important that your office notes include not just diagnoses, prognoses, and comments on slight medical improvements, but also:

  • Details about clinical symptoms
  • Specific findings about what the patient can and can’t do
  • Support for your finding that the patient is disabled

Social Security disability is meant to relieve financial stress for people facing very difficult times. Accordingly, it is important that you are aware of how your notes may impact a finding of eligibility and that you talk to your patients about the option of Social Security disability.

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Morgan & Weisbrod LLP

by Paul B. Burkhalter
Managing Partner of Morgan & Weisbrod, Board Certified in Social Security Disability Law.


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