Talking to Your Doctor About Your Disability Case

While you, as a patient, cannot directly control what information your doctor puts into your medical record, there are a few important points to remember in describing pain and limitations which impact you in your daily life which should be detailed to your doctor.

• Avoid Conclusory Statements or Opinions and Provide Detail about Limitations.

When speaking to your doctor, describe the factual basis of your disability, rather than simply stating that you are disabled. You must give specific reasons to your doctor that explain why you should be awarded disability benefits. For example, if your back or neck pain prevents sitting or walking for extended periods, tell your doctor how long you are able to sit (or stand) before the pain affects you to the point where you need a break (rest or lie down, etc). If you have joint pain or back pain and are unable to stand or walk for extended periods of time, attempt to describe examples of how that impacts you doing household chores or other daily living activities or tasks. If you have difficulty lifting/carrying things, describe examples: what tasks are difficult for you to do around the house or in the community that you encounter in daily living activities. Or, if you are unable to concentrate due to pain or psychological distractions or other limitations and are unable to do your work or complete the task because of the limitation(s), then attempt to specify how frequently, how long, how severe, etc. These small details become important to show your condition impacts “residual" physical or psychological functioning. 

• If You Have Pain, Describe Your Pain Objectively on a 1-10 Scale. 

It's best to describe the severity of your pain to your doctor on a 1-10 scale, where "1" is minimal or no pain, and "10" is the kind of pain that takes you to the Emergency Room. Consider that you will have “good days” and “bad days” with respect to pain levels and attempt to describe what flareup days and how long they last (if more than a single day). Doctors are used to using this kind of pain scale, and it's a more objective way of documenting pain, which is a purely subjective matter.

• You Have the Right to Look at Your Medical Records.

Under HIPAA ("Health Insurance Portability and Accountability Act), you have the right to review your medical records. That's something you should remember. You also have the right to request your doctor make an addendum to your medcal records if you see something that's not accurate. Amending the medical record does not mean that a doctor can change what he/she has already entered into your chart, however the doctor can add a statement to clarify the entry he/she has made in your chart.