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Book Information
Book Excerpt - Chapter 4 - Medical Evidence - The Determining Factor
“Section 5 – Medications"
The intent of Section 5, Medications, is to show the significance that medications play in the treatment plan. True or not, the use of medications implies or suggests the severity of symptoms. This is particularly true of pain relievers. It would be difficult to believe an allegation of severe pain, if there were no corresponding medication for pain relief. Medication is the most common aspect of a treatment plan.
The first question asks if you currently take medication and provide two boxes for a yes or no response. If the answer is yes, then Section 5 asks you to complete a simple, four-column table that specifies the name of the medication, the doctor that prescribed it, the reason for the medication and any side effects from the medication.
The CD contains a template called Section 5 – Medications, for recording your medications. If you use vitamins or herbal supplements as a treatment for your illness, include them on the list of medications under a separate heading of vitamins.
If any medication has side effects, be sure to describe the reaction. Side effects from medications can contribute to the inability to perform typical work duties. Prescriptions for pain and muscle relaxers are examples of drugs that inhibit mental functioning, impair physical reactions and prohibit safe operation of equipment.
Section 5 ignores therapeutic information, including dosage and frequency. Submitting additional information about prescription usage re-enforces medication as an invaluable treatment tool. Pharmacy records and medication summaries offer the examiner a valuable perspective. Pharmacies can generate, upon request, a history of medications that contain the date the prescription was filled, drug name, strength, quantity, prescribing physician and price.
The following is an excerpt from a prescription history report generated by the pharmacy.
Prescription History Report
Pharmacies will generate a prescription history for any given period. If more than one pharmacy is used, get a prescription history report from each pharmacy. At a minimum, request records for a six-month period.
Below is an excerpt from a prescription summary using the data from the prescription history report. This particular excerpt shows medications for sleep and a partial list of pain medications. The following is an excerpt from the sample application, Prescription Summary. Medications and dates are grouped under the symptom or condition. In this example the conditions are “Sleep Disturbance” and ”Pain, Muscle Spasm and Migraines”.
Prescription Summary Excerpt
Sleep Disturbance
|
Medications |
Dates |
|
Ambien |
10/8/00, 11/22/00, 2/15/01 |
|
Desyrl. |
2/16/01,3/29/01, 4/23/01, 5/23/01, 6/15/01, 11/20/01, 12/00/01 |
Pain, Muscle Spasm and Migraines
|
Medications |
Dates |
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Vicodin |
7/21/00, 10/16/00, 11/17/00, 12/28/00, 2/5/01, 2/20/01, 3/9/01, 3/23/01, 4/13/01, 4/27/01, 5/17/01, 7/12/01, 1/11/02 |
|
Vioxx |
3/12/01, 4/5/01, 5/8/01, 6/6/01, 7/20/01, |
Section 6 – Tests
Section 6, Tests, is a critical section in the application. Diagnostic testing constitutes conclusive evidence of a severe illness. This is the proof that the SSA needs to justify a medically determinable impairment, an absolute necessity to receive disability benefits.
The application lists thirteen tests in a table to record when the test was performed, where it was done, and who sent you for the test. The thirteen listed tests are; EKG, treadmill, cardiac catheterization, biopsy, hearing, vision, IQ, EEG, HIV, blood, breathing, x-ray, and MRI or CT scan. You may or may not have had these tests. More importantly, these tests may not substantiate your disabling illnesses.
Section 6 -
Tests
This table of tests is, for the majority of applicants, inadequate to report all the testing completed in the course of diagnosing and treating an illness. In order to accurately report testing it is necessary to summarize test results.
The application does not ask for results; the assumption is that the SSA examiner will obtain copies of the test results. Do not rely on SSA to collect test results. It’s the claimant’s responsibility to obtain and submit all tests or testing summaries since the onset of the disabling illness or injury. As mentioned early, the findings, opinions, conclusions and impressions of test results are included in a report from a physician who specializes in interpreting diagnostic tests. To obtain copies of the test results, contact the facility that performed the test.”
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