Monday, January 19, 2015

The Illegible Medical Records Problem

Over the years, my office has developed great expertise in deciphering the awful scribbles and poor hand writing of some physicians.  However, in some instances, a doctor's  handwriting is so bad  that it  is impossible use the medical record to support our client's claim.  
Bad handwriting can seriously interfere with your Social Security Disability or Long Term Disability Claim.  If the examiner reviewing your case cannot understand your doctor's notes, your case is less likely to be granted.  The problem of illegible medical records not only causes problems for disability benefit applications.  It is well established that illegible medical notes can also harm patient care.  A 1986 study from the New England Journal of Medicine found that out of 50 outpatient notes, 16% of the all words were illegible.  This means that on an average, one out of every six words could not be deciphered.  Besides affecting your chances wining your SSDI or LTD case, bad handwriting from doctors result in lost time and money, medication errors and bad communication between different providers. 
The solution to problem of bad hand writing is obvious: switch to a computer based system for taking  medical notes. Unfortunately, many dinosaurs in the field of medicine are still unaware of the digital era.
If you are seeking long term disability and/or Social Security Disability Benefits and you have a medical provider that has poor penmanship, here are some suggestions of steps that can be taken to improve the quality of medical evidence presented with your claim:
  • Prepare a questionnaire for your doctor to complete with very specific questions.  In our office we call these questionnaires "Medical Source Statements", however, many disability lawyers also refer to these forms as residual functional capacity "RFC" forms.  In many instances, it is a good idea to have specific boxes that your doctor can check in order to prevent him from writing too many illegible scribbles in the form.  Preparing this questionnaire can help you narrow down some of the specific medical issues in your case and get specific responses pertaining to your medical condition.
  • Try to transcribe some of the medical records and present them to your doctor for his approval. At the end of the transcription, you can provide a space for his signature attesting that your transcription is correct.  You can also be more diplomatic and resourceful and hire your own medical consultant to do the transcription.  Your medical consultant can then write the doctor asking for his approval of the transcription.
  • You can ask your doctor to agree with another medical expert's opinion by signing it.  You can provide him a copy of the other doctor's medical opinion and ask him in writing whether he agrees.  This is a way to, at least, give some weigh to the credibility a medical provider's whose record's would otherwise have very little weight in your case.
  • Finally, under HIPPA laws you are allowed to request that a medical provider make corrections on medical records that are inaccurate or illegible.  The problem with this option is that it might take a while for the doctor or hospital to make this change.  You are probably better off trying to address the issue informally with your doctor and ask him whether he can write a letter for your disability claim explaining the any illegible statements on the record.