Your Medical Records and Social Security Disability

What appears in your medical records will be absolutely critical for Social Security Disability. Why? The statutes and regulations governing Social Security Disability (SSD) provides ultimate authority on the determination if you meet the definition of disabled to the Social Security Administration. In making that determination, there is a review of your medical records of the medical providers that you provided on your application for benefits.

Your medical providers document your visits to their office. Specifically, most medical records are similarly organized with categories of information.

  1. History. Most medical records have a patient history section where the doctor records why you are present for treatment. Here they also take down what you say to the doctor. That is precisely why it is absolutely critical that you are accurate in what you tell your doctor.
  2. Current Symptoms. Here the doctor records what current symptoms you are experiencing. It is important you tell your doctor about all of your symptoms.
  3. Physical Examination. This is where you doctor records the findings form your physical examination that specific day.
  4. Assessment/Diagnosis. This is obviously the diagnosis the doctor provides regarding your medical condition(s). Often times, this is a very critical part of the record from review purposes.
  5. Plan/Future Treatment. This is the part of the medical record where your doctor records the next treatment steps for your condition.

Of course, not all medical records are the same. These are generalized categories for standard medical records.

In determining whether you are disabled, Social Security regulations place special emphasis on treating medical providers. The reasons are obvious — your treating doctors have a much more thorough understanding of your condition, have treated you multiple times, and can provide detailed views of your diagnosis, treatment plan, and treatment response.

It is important to note that Social Security can only consider and review medical records from medical providers they know about. If you do not provide Social Security with all your doctors names, if you do not provide my firm all of your doctors name, then Social Security has no way to know and therefore can’t consider those records. Missing records often can be that critical additional piece of evidence to push you over the top. It can also speed up the processing of your application.

Mooney Law assists many clients with the SSD application process to put the best foot forward in the initial application. If you are denied, we take care of consistently requesting and uploading medical records to Social Security while we await your hearing. If you are applying for or have been denied Social Security Disability, call Mooney Law for a FREE consultation at 833-MOONEYLAW. We represent disabled clients throughout Pennsylvania and Maryland.

Mark Buterbaugh

Attorney representing injured workers and Social Security Disability clients in Pennsylvania and Maryland.