Medical Records for Social Security Disability

Medical Evidence

Under both the Title II and Title XVI programs, medical evidence is the cornerstone for the determination of disability.

Each person who files a disability claim is responsible for providing medical evidence showing he or she has an impairment (or impairments) and the severity of the impairment(s).  This medical evidence generally comes from sources that have treated or evaluated the claimant for his or her impairment(s).  Our office will gather your records from the different doctors and hospitals that have treated you, as we process your disability claim.

Acceptable Medical Sources

Documentation of the existence of a claimant’s impairment must come from medical professionals defined by the Social Security Administration regulations as “acceptable medical sources.” Once the existence of an impairment is established, all the medical and non-medical evidence is considered in assessing impairment severity.
Acceptable medical sources are:

  • licensed physicians (medical or osteopathic doctors);
  • licensed or certified psychologists including school psychologists (and other licensed or certified individuals with other titles who perform the same function as school psychologists in a school setting) only for purposes of establishing mental retardation, learning disabilities, and borderline intellectual functioning ;
  • licensed optometrists only for purposes of establishing visual disorders (except in the U.S. Virgin Islands where licensed optometrists are acceptable medical sources only for the measurement of visual acuity and visual fields);
  • licensed podiatrists only for purposes of establishing impairments of the foot, or foot and  the ankle, depending on whether the state in which the podiatrist practices permits the practice of podiatry on the foot only, or the foot and the ankle; and
  • qualified speech-language pathologists only for purposes of establishing speech or language impairments. For this source, “qualified” means that the speech-language pathologist must be licensed by the state education agency in the state in which he or she practices, or hold a Certificate of Clinical Competence from the American Speech-Language-Hearing Association.

Medical Evidence from Treating Sources

Currently, many disability claims are decided based on medical evidence from treating sources. Social Security Administration regulations place special emphasis on evidence from treating sources because they are likely to be the medical professionals most able to provide a detailed picture of the claimant’s impairment(s) and may bring a unique perspective to the medical evidence that cannot be obtained from the medical findings alone or from reports of individual examinations or brief hospitalizations. Therefore, timely, accurate, and adequate medical reports from treating sources accelerate the processing of the claim because they can greatly reduce or eliminate the need for additional medical evidence to complete the claim.

Medical Evidence From Health Facilities

The Social Security Administration also requests copies of medical evidence from hospitals, clinics, or other health facilities where a claimant has been treated. All medical reports received are considered during the disability determination process.

Other Evidence

Information from other sources may also help show the extent to which an individual’s impairment(s) affects his or her ability to function in a work setting; or in the case of a child, the ability to function compared to that of children the same age who do not have impairments. Other sources include public and private agencies, non‑medical sources such as schools, parents and caregivers, social workers and employers, and other practitioners such as naturopaths, chiropractors, and audiologists.

Medical Reports

Physicians, psychologists, and other health professionals are frequently asked by the Social Security Administration to submit reports about an individual’s impairment(s). Therefore, it is important to know what evidence the Social Security Administration needs. Medical reports should include:

  • medical history;
  • clinical findings (such as the results of physical or mental status examinations);
  • laboratory findings (such as blood pressure, x-rays);
  • diagnosis;
  • treatment prescribed with response and prognosis;
  • a statement about what the claimant can still do despite his or her impairment(s), based on the medical source’s findings on the above factors.
  • if the claimant is an adult age 18 or over, this statement should describe, but is not limited to, the claimant’s ability to perform work-related activities, such as sitting, standing, walking, lifting, carrying, handling objects, hearing, speaking, and traveling.
  • in adult cases involving mental impairments or mental functional limitations, this statement should describe the claimant’s capacity to understand, to carry out and remember instructions, and to respond appropriately to supervision, coworkers, and work pressures in a work setting.

If the claimant is a child under age 18, this statement should describe the child’s functional limitations compared to children his or her age who do not have impairments  in acquiring and using information, attending and completing tasks, interacting and relating with others, moving about and manipulating objects, caring for yourself, and health and physical well-being.

The best medical records are those that are typed, mention all of the patient’s complaints, show the results of examination, note what treatment was given, state the response to treatment, and mention future plans and a prognosis. Unfortunately, many records are difficult to read or don’t contain enough information to determine disability.

For example, someone may apply for disability benefits based on their arthritis. When the disability examiners review the records provided by the treating doctor, often the file contains a few scribbles that the patient has joint pains and arthritis, and further notes that some form of treatment has been given. Often, medical records contain no description of diseased joints, no range of motion test results, and no x-rays. The Social Security Administration spends extensive time and money each year obtaining data from consultative examinations, x-rays, and other lab tests.

The Social Security Administration cannot evaluate medical records that are scribbled and unreadable, nor can they evaluate medical records that lack significant information about your condition.

If your physician is willing to support your claim for social security disability, then you should probably go one step further and ask the physician to be sure your records include three important pieces of information: 1) Your date of onset (when symptoms first began to be disabling); 2) your current level of disability; and 3) your prognosis (if your condition is likely to improve, stay the same, or worsen over time).

Finally, the medical records that carry the most weight are evidence statements from your treating physician. This is because a treating physician (a doctor you see regularly) will generally know your medical condition better than any other source.