You might be surprised to learn how difficult it is to ensure that what you tell your doctor actually gets into your treatment notes. Gone are the days when your doctor scratched a few handwritten notes about your visit on a notepad. Today many doctors only use “canned” treatment notes.
What Are “Canned” Treatment Notes?
Before you even speak one word to your doctor, a computer program generates many pages of automatic answers to virtually every conceivable medical condition you might discuss. It also repeats answers you may have mentioned to the nurse/doctor several years before that encounter. For example, I have seen many examples where a client stopped smoking years prior, yet the doctor’s computer-generated program says the patient continues to smoke.
Many canned programs will generate 7-10 single-spaced, typed pages after a 5-minute consultation! Even if patients never mention various symptoms, the computer program indicates the patient was specifically asked about a condition and specifically denied any such problem. In other words, things you never said can be used by some judges to deny your Social Security disability claim because your doctor’s note said you “denied” any such pain.
What Can I Do?
The best way to overcome this problem is to be focused when asked why you need to see the doctor. Know your top two or three reasons for visiting the doctor, and don’t be afraid to repeat yourself. Tell the scheduler, tell the nurse, and tell your doctor: “My back pain is so bad I can’t sit through dinner and my leg gets numb, my feet burn even when I am sitting, and the pain is so severe I can’t even concentrate well enough to read.”
A statement like this lets the doctor know exactly what problems you are experiencing, how severe they are, and finally, helps the doctor provide the most accurate plan to improve your situation. Do this every time you visit any of your doctors.
In these computer-generated (canned) treatment notes, the program allows the doctor (or nurse) to write a few words to explain why you are there and they are usually reflected at the top of the treatment note. Other than that, the doctor has to specifically change an answer already generated by the computer program (which doesn’t happen very often). Therefore, it is important that you choose your words wisely.
by Paul B. Burkhalter Managing Partner of Morgan & Weisbrod, Board Certified in Social Security Disability Law.