Electronic Medical Records: What You Don’t Tell Your Doctor Might Hurt Your Disability Claim

Over the last ten years, there has been an increasing movement away from paper records and toward Electronic Medical Records (EMR).  This move has been accelerated by the federal government’s mandate that doctors who treat Medicare and Medicaid patients must have adopted and implemented EMR systems as of January 1, 2014.

There are many benefits to using EMR.  They can facilitate patient care between referring doctors, improve data tracking over time, increase efficiency and reduce errors.  However, EMR systems have drawbacks when they are used for purposes never intended, such as to document a disability claim.

Many EMR systems allow the doctor to input his findings for every major system in the human body, such as the cardiovascular, musculoskeletal, gastrointestinal, neurological and psychiatric systems.  However, if the doctor does not put in something regarding one of the symptoms, the default setting on the EMR will report the system as being “within normal limits” or that the patient has “no complaints.”  The concern with this from a disability perspective occurs when a patient sees his doctor for a condition unrelated to his disability.

For example, a patient with a history of degenerative disc disease could visit his doctor for an unrelated infection or illness.  Since the doctor is conducting only a limited examination for purposes of treating the presenting illness, he may not input any information related to the patient’s disabling condition.  The EMR will then generate an inaccurate record stating that the patient’s musculoskeletal system and neurological system are within normal limits.

Disability insurance carriers can then use these default settings to their own advantage to raise questions about the severity of the claimed disability, justify an independent medical examination or functional capacity evaluation, or support a claim termination.  For patients who are receiving disability benefits, it is therefore important to know what their medical records look like and to effectively communicate with their physicians to ensure that their conditions and symptoms are accurately recorded on each visit.


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