by David A. Morton III, M.D., former SSA medical consultant
For a Social Security disability (or SSI) case, medical evidence takes many forms, including physician exmination and treatment notes, mental health records, bloodwork panels, and reports of imaging studies (MRI, CAT scan, and X-rays). Timely, accurate, and sufficient medical evidence from your treating doctors can greatly reduce or eliminate the need for the Social Security Administration (SSA) to obtain additional medical evidence, which means you can get a faster determination on your disability claim. Timely, accurate, and sufficient mean the following:
Timely records are recent enough to be relevant to your current medical condition. How recent is a matter of medical judgment, depending on the disorder. A condition that is rapidly changing requires more up-to-date information than one that is slowly progressive or unchanged for years. Generally, the SSA likes to have records no older than six months. That doesn’t mean older records aren’t important. Records dating back for many years may help provide the medical big picture.
Accurate records correctly describe your condition according to the standards of acceptable medical sources. To use a common example, a chiropractor can describe subluxation (slippage) of your spine on x-rays, but this will not be considered accurate if an acceptable medical source reports normal x-rays. (A chiropractor's records are not considered evidence by the Social Security Disability program since chiropractors are not medical doctors. However, the X-rays taken by a chiropractor can be admissible as evidence.) Also, a medical opinion that is countered by objective evidence will not be considered accurate. For instance, a treating medical doctor’s records that say you can’t walk one block because of chest pain will be rejected if specific exercise testing shows that you can do much more exercise.
Sufficient medical records contain enough accurate information from acceptable medical sources to allow the SSA to make an independent medical judgment regarding the nature and severity of your medical condition. For example, an allegation and diagnosis of cancer is not sufficient. The SSA will want to know: Did a biopsy prove the cancer’s presence? What kind? Where in the body? When did symptoms appear? What did a physical examination show? What did x-rays and other imaging tests show? What did blood tests show? Did you have surgery? Did it remove all of the cancer? Did you have chemotherapy? What side effects did you suffer, if any? Did you have radiation therapy? What were the results? (Read more about the medical evidence required for disability based on cancer. Similarly, the evidence requirements for HIV-AIDS disability are specific and involved.)
It is not enough for your doctor to start keeping detailed records when you apply for disability. The SSA would like to see "longitudinal" records, that is, records that include your medical history, especially if you hope to get retroactive disability benefits.
Example: You were sick for six months before you applied for disability and were unable to work during that time. You might be eligible for a retroactive award of benefits for the six months you couldn’t work. But if your doctor does not have detailed medical records for the entire period he has been seeing you, you might not be able to prove you were unable to work during those six months. There is no way for your doctor to believably recreate detailed medical records from memory.
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 don’t contain enough information to determine disability.
For example, many people 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 SSA spends extensive time and money each year obtaining data from consultative examinations, x-rays, and other lab tests.
The SSA cannot evaluate medical records that are scribbled and unreadable, nor can they evaluate medical records that lack significant information about your condition.
For instance, to qualify for disability based on epilepsy, you must have had a certain number of seizures during a specified time period, and your medical records must include a description of a typical seizure. But physicians--even neurologists who specialize in treating epileptics--often do not record the number of seizures a patient has had between visits, even though they should, in the event an adjustment of medication might be needed. Nor do physicians usually describe a seizure in detail in their records, though they will note the type of seizure involved and drugs given. The SSA requires a number of other things to evaluate the severity of epilepsy, such as whether or not you cooperate in taking medication and the blood levels of drugs used to treat the epilepsy. These are also often missing from a treating doctor’s file. Read more about the disability requirements for epilepsy.
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. RFC forms are ideal for this purpose.
Learn about how a disability attorney can develop the medical evidence that will best help your case.