Medical Records Are Crucial — By Beth Sufian, JD

In this blog we provide information related to medical records and their importance to a person with CF.

Nothing in this blog post is meant to be legal advice about your specific situation and is only meant as information.  

Medical Records Are Crucial

Detailed and accurate medical records can help with a variety of issues. Medical records are important for those applying for Social Security benefits or undergoing an SSA Continuing Disability Review. Medical records may also be important when asking for accommodations at work or school or when applying for FMLA, short term disability or long term disability.

Typically the basis for an approval or denial of Social Security benefits is found in a person’s medical records. In addition, insurance companies are increasingly requesting medical records to determine if coverage for expensive treatment will be provided. Schools and employers may also require medical records if a person requests an accommodation at school or work.

While there is no exhaustive list of what should be included in a person’s medical records it is helpful if medical records contain information about daily limitations that interfere or that prevent a person from working full time or attending school.

Medical records often do not contain details needed to obtain insurance coverage, Social Security benefits, employment or school modifications.  It is important to make sure a CF Center records medical issues and limitations on daily life activities in the medical records.

When a person wants their medical records to support an application for Social Security benefits or a Continuing Disability Review or short or long term disability benefits the specific information is important.

Information such as the time it takes to perform each breathing treatment done in the morning and each treatment done at night, the number and duration of airway clearance treatments, the need for naps during the day, issues with coughing up blood or digestive issues, issues with memory, concentration or stamina, coughing at night or insomnia caused by medication side effects may all important.

The time spent managing CF related diabetes is also important.  If diabetes is difficult to control then it is important that the medical records discuss the problems CFRD is causing for the person with CF.

Any information that supports a finding that the person cannot work full time is helpful for a Social Security application or a Continuing Disability Review.

It is a good idea to keep a log of issues a person is having in between CF Clinic appointments. A spiral notebook is helpful.   Dates health issues were experienced are crucial.  For example, December 12, 2016 Hemoptysis. Coughed up a teaspoon of blood.  Another example would be, December 15, 2016 severe stomach problems requiring rest for 2 hours mid day.

Often a person might forget issues they were having a month before their clinic visit.  Sometimes there is so much to discuss at a clinic visit that some things are not discussed and so are not recorded in the medical records.  A notebook containing a log of issues a person had will be helpful at the clinic visit.  The person can tell the CF Center team member what happened and ask that the information be included in their medical record.

A letter written by a physician at the time a person applies for SSA benefits is NOT as effective as detailed medical records for a 12 month period. Records that document medical issues and issues with performing daily life activities are important.

There is no guarantee that including such information in a person’s medical records will result in an approval for SSA benefits or insurance coverage for a needed treatment or modifications at school. A person requesting modifications at work must be careful not to provide too much information about limitations. If the person cannot perform the essential functions of the job with or without a reasonable accommodation the person may be found to be ineligible for the job.

If you have questions about the legal rights of a person with CF you can email the CF Legal Information Hotline and set up a time to speak with an attorney who can provide information.

Email- or call
1-800-622-0385. All contacts are free and confidential.

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