#4) Your Medical Records: Do You Know What’s in Them?

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By Cheryl Coon

The information provided in this article is intended to give a general overview of the topic and is not intended as legal advice. For information specific to your situation, please talk with your Social Security/Disability professional.

Article #4, Your Medical Records:  Do You Know What’s in Them?

Our medical records follow us wherever we go and have a big impact on our lives.  Everything from what our health care providers know about us to decisions on our applications for social security disability are affected by what is in our medical records.  But all too often, our medical records are incomplete or even inaccurate…and we don’t even know it. 

Have you ever tried to collect your own medical records for years passed?  It’s a good idea.  You might be surprised to find errrors in them.  Some errors are just amusing ((my records said I have three children. Really?  That’s news to me!)  But what is…and is not…in your records can be alarming. 

As a social security disability lawyer, my clients’s cases depend upon their medical evidence to demonstrate what they have been diagnosed with and how their daily symptoms affect their lives, including their ability to work.  But frequently clients and I are surprised to see references to drug and alcohol use or to improvement, without noting that the baseline is still too severe to work.  Other times we’re surprised to see no mention of problems my clients remember discussing.

So I am very excited about a new approach that will make it much easier to obtain and if necessary, correct, your medical record.  More than one million patients in Oregon and Southwest Washington soon will have electronic access to their medical records.  The initiative is called Open Notes.”

How it began

The OpenNotes initiative began as a yearlong experiment in 2010 to investigate how patients and doctors would feel about sharing chart notes from visits.  By the end of the experiment, researchers reported that patients with access to their doctors’ notes felt in more control of their care, reported better understanding of their health and conditions, improved recall of their care plan, and being more likely to take their medications as prescribed.  In addition, researchers reported that very few doctors reported longer visits or taking more time outside of visits to address patient concerns as a result of sharing notes.

How it works

When you see doctors or other health care providers for an appointment, you may notice them writing notes by hand or on a computer during the visit. These notes, which summarize what was discussed between the doctor and you, and what the doctor found or measured during the appointment, become a part of your medical record.

Although patients have the right to review their medical records, including the notes doctors write, most people generally don’t ask and most doctors don’t offer.

Visit notes may include:

  • What you and your doctor discussed during your visit, including symptoms and your doctor’s physical exam findings, diagnosis, and plan for treatment;
  • Why your doctor ordered a specific lab test or prescribed a certain medication;
  • What needs to be done after the visit, such as additional tests or studies, follow up appointments, or referrals to a specialist.

Who will be use Open Notes

The health providers that have now committed to “open notes” include Kaiser Permanente Northwest, Legacy Health, Oregon Health & Science University, Providence Medical Group Oregon, The Portland Clinic, The Vancouver Clinic, the Portland VA Medical Center, OCHIN and Salem Health.

Each of these groups is already practicing open notes in some form or intends to do so beginning sometime in 2014 or 2015.  Major systems implementing Open Notes already include the Mayo Clinic and the Cleveland Clinic, in addition to the VA.

Can Any Doctor Participate?

The folks sponsoring this initiative appear ready to include anyone who is interested.  If it makes sense to you, tell your doctor about it!

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Cheryl Coon previously led the social security disability section of Swanson Thomas Coon & Newton of Portland, Oregon, where she represented disabled individuals seeking benefits, at all stages of the process from application to federal court appeals.

Refugee Disability Benefits of Oregon
Refugee Disability Benefits of Oregon

In June 2016, Cheryl Coon founded RDBO. Refugee Disability Benefits of Oregon. RDBO takes a unique approach, in which attorney Cheryl Coon, works closely with health care providers, case managers and counselors, as well as the refugees they serve, to ensure that refugees’ cases are presented competently and compassionately. We handle cases at every step of the disability process, from initial application to hearing to federal court.

The social security disability process can be frustrating. We believe it is important for potential applicants to be realistic about their chances for approval. We carefully evaluate the merits of each person’s case and suggest alternatives when we do not believe their case is strong. These alternatives may range from vocational assistance to waiting until a stronger medical record has been established.

Cheryl F. Coon, Attorney at Law
Refugee Disability Benefits Oregon
1137 SW Broadway
Portland OR 97205

Phone: 971-270-0755
Website: www.rdbo.org
Email: cheryl@rdbo.org