What Do Your Medical Records Have to Say for Social Security to decide You have a Disabling Condition?

Social Security considers medical records from acceptable medical sources when making their disability decisions.

Social Security views medical records from licensed physicians, certified psychologists, and licensed optometrists to be acceptable medical treatment sources. Additionally, Social Security obtains medical records from hospitals, clinics, or other treatment facilities where an individual has been treated. Social Security values medical treatment records from an individual's treating medical professionals because it provides a better longitudinal view of an individual's impairments and how these impairments affect the individuals ability to perform routine daily activities.

If your treating physician provides a medical report (statement), i.e. a a medical source statement or RFC form to Social Security, it may be very helpful to your chances of winning your disability claim.

Social Security needs the following evidence to be included in the statement. There needs to be an up to date medical history, objective clinical results (physicals and mental status evaluations), laboratory results (x-rays, blood tests, CT scans, MRIs, etc.), a clear diagnosis, treatment methods and treatment response, along with a prognosis.

Additionally, Social Security would like for your treating medical professional to give an opinion as to what they feel you are able to do in spite of the limitations caused by your impairment (Social Security calls this your residual functional capacity). This statement should explain the effect your condition(s) or impairment(s) has on your ability to perform work activities, like walking, standing, lifting, carrying, fine motor activities, hearing, seeing, or even driving or traveling.

If your disability claim involves mental treatment sources, their statements should describe an individual's ability to respond to the pressures of a work environment, the ability to understand and remember instructions, and the ability to respond to coworkers and supervisors in an appropriate manner.

The above information is what Social Security would like to find in your medical records. If your medical records illustrate that your physical or mental residual functional capacity is so restrictive that you are unable to perform simple routine repetitive tasks in a work environment, Social Security is likely to consider that you have a disabling condition that may meet the criteria for awarding disability benefits.

About the Author: Tim Moore is a former Social Security Disability Examiner in North Carolina, has been interviewed by the NY Times and the LA Times on the disability system, and is an Accredited Disability Representative (ADR) in North Carolina. For assistance on a disability application or Appeal in NC, click here.

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