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Helping Your Doctor Document Your Condition
Obviously, it's not you, but your doctor, who has control as to what medical information goes into your chart. However, surprisingly, you have a lot more to do with that than you may appreciate. That's because it's you that tells the doctor what symptoms you have, how often and for how long you have them, how severe or intense they are, how they interfere with your daily activities, and how they impair your ability to perform the essential duties of your job.
Telling your doctor about your symptoms is especially important when it comes to subjective, self-reported symptoms. These are symptoms that are your own perceptions, most notably such symptoms as painand fatigue, which only you feel and only you can know.
It's often good to keep a daily diary of such symptoms at home, so that when you go into the doctor's office to see the doctor, you can refer to or show the doctor your symptoms and how they affect your functionality.
Reviewing Your Medical Records
Under HIPAA, CFR § 164.526, you as a patient have the legal right to copy, inspect and to request an amendment to the medical information your doctor puts into your chart. We recommend that you do that periodically to make certain that the information about your disability that you tell the doctor is getting into the chart. If it's not, speak to the doctor about that. Ask him to amend the chart if it is appropriate and check again.
ERISA law is complicated. At Law Med, we are ERISA knowledgeable and experienced.
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