Medical records are vital, and the most important evidence you have to support your case. No matter how sick you may be, SSA cannot approve your claim if you don’t have the appropriate medical evidence to support a favorable decision.
Medical Records
Your medical records should consist of two parts: Diagnoses and Limitations
Unfortunately, not all doctors keep records with this information. In fact, most records are lacking information about limitations. So, it is a good idea for you to review your limitations at every visit with every doctor.
DIAGNOSES: You need more than a diagnoses listed in your medical records. You need supporting evidence of that diagnoses!
How did you end up with your particular diagnosis? Was there a blood test? An x-ray? Did you meet some other criteria that showed the doctor you are suffering from this specific ailment?
Just going to the doctor with your complaints is not enough. There needs to be some sort of test or other confirmation of your diagnosis. Social Security likes to see x-rays, MRIs, and other imaging tests. They want to know what methods your doctor used to determine which physical or mental problems you are experiencing. Social Security wants to know how your doctor came up with your diagnosis.
LIMITATIONS: How do your diagnoses affect your limitations? How does your diagnosis affect the way that you were able to sit, stand, walk, remember, or interact with other people?
While it is important for your doctor to note in your medical records how they arrived at your diagnosis, it is also important for your doctor to note how these diagnoses will limit you in your everyday life. See the next section for more information on how your doctor can do this.
Medical Opinion Letters:
Another type of medical evidence is a medical opinion letter from your doctor. You may ask your doctor to write a letter on your behalf which describes your diagnoses and limitations.
It’s very important that this letter describes the limitations you have in everyday life.
For example: “My patient cannot lift more than 10 pounds. He cannot climb stairs, stoop, crawl, or bend as a result of his back pain. His pain will persist long-term, and requires strong pain prescriptions that impair judgment and reaction time. He should avoid driving, and other dangerous situations. Despite the use of pain medication, back pain will continue to be severe enough to cause him to miss work at least one day per week, or 3 to 4 days per month.”
Medical Source Statement:
Sometimes Social Security will send a form to your doctor, asking for their medical opinion.
If you have an attorney, your attorney may give you a form to take to your doctor, as well. Some attorneys send the forms directly to the doctor’s office. However, we have found that doctors are far more likely to actually complete the forms if the patient brings it with them to an appointment. Otherwise, the doctors either refused to complete the form or the forms just get lost in the office paperwork.
Originally Published: December 04, 2018
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