How are medical records and work history used to determine a Social Security Disability claim?

How are medical records and work history used to determine a Social Security Disability claim? This involves the step of the SSD application process in which the claim is handled by a disability examiner at an agency known as DDS, or disability determination services.

After a person A) contacts the social security administration (ideally, by calling or visiting a local social security office), B) has their disability inteview, and then C) has a disability application on file, the claim is sent to disability determination services (in some states, DDS may be known by other names such as the bureau of disability determination) where it is assigned to a disability examiner.

The disability examiner will focus initially on getting the medical records gathered. This occurs on day one of the examiner receiving the claim from the social security office where the intake was done. Using the information provided by the claimant at the time they filed their application for SSD or SSI, the examiner will start sending out letters to the various doctors and hospitals who have provided treatment to the claimant.

Getting the medical evidence gathered is what accounts for the largest portion of the waiting time. And the time required to get the records may amount to just a few weeks or several months. It is not uncommon for disability examiners to have to send multiple requests for records to the same facility, and make multiple follow up calls, and then fax previously mailed requests.

Once the medical records have been received, however, the disability examiner will review them, consult with a medical physician who is assigned to his or her case processing unit, and then determine what the claimant's residual functional capacity is.

The residual functional capacity, or RFC, is a measurement (some would say a guess) as to what the claimant is still capable of doing. For example, are they still capable of lifing 10 pounds frequently, or 50 pounds occasionally? Are they incapable of lifting more than this? Are they unable to sit for more than two hours at a time due to lower back pain? Are they unable to reach overhead, or grasp small objects? Are they unable to remember instructions? Are they unable to get up on ladders due to back issues, vertigo, or epilepsy.

These are the things addressed by a rating of a person's RFC. And bear this in mind that this is for a physical RFC; mental limitations are rated on an MRFC, or mental residual functional capacity, form.

After a disability examiner rates a claimant's RFC, they can then compare this rating to what the claimant did in their past work. Depending on what the claimant's past jobs required of them, and what their current capabilities are, they may be capable of going back to a former job (in which case they would be denied for disability), or unable to do this.

If a claimant is found to be unable to do a former job, then the disability examiner will examine whether or not it is feasible for the claimant to use their acquired skills and education to find some type of other work. When other work is considered, the examiner will also consider the claimant's education and their current level of physical and mental functioning (as rated on their mental and physical RFC assessments).

Medical records and the evidence they contain form the foundation for all decisions on disability claims. However, medical evidence is used in conjunction with the information about a claimant's history of work and the skills they have acquired in the course of their work history. This is only fair considering that individuals who had jobs requiring medium and heavy exertion will be less likely to do these jobs if they have physical limitations and also as they get older.

Additionally, individuals who have fewer transferrable skills will be less likely to find themselves in the position of being able to switch to some new form of employment.

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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