Social Security Disability, Medical Records, and a Person's Limitations

How do medical records show limitations? That is the problem for most individuals who receive a disability claim denial since most medical records do not indicate the limitations that are suffered by patients. Medical records will usually refer to a patient's diagnosed conditions, the type of treatment they have received, or are receiving, and their complaints and symptoms.

But doctors are simply not in the habit of indicating in their notes if a patient is having difficulty sitting for longer than a certain period, or difficulty standing or walking for more than a certain amount of time. Yet, this is the information that social security needs in order to make an approval on a disability claim.

Notations in the medical records as to a person's limitations can allow a disability examiner or judge to get an overall idea of an individual's degree of limitations. It can also allow the decison-maker on a disability claim to determine if the claimant can return to their past work. If it is obvious that the claimant cannot return to their past work, the decision-maker can make a determination as to whether or not the claimant could do some type of other work.

If that is not possible, of course, and the claimant's condition will effectively rule out the ability to work for at least one full year, then they will have met the social security administation definition of disability and will be eligible to receive disability benefits.

When the medical records that have been received by the disability examiner working on the case contain very little reference to how limited a person is as a result of their condition, it is often helpful to have a detailed statement from the claimant's treating physician.

These statements are usually called medical source statements and they allow the claimant's doctor to provide the necessary that the doctor's treatment notes did not. Medical source statements, if they are detailed, objective, and supported by the rest of the claimant's medical record, can assist in winning a claim. But they are usually of little benefit unless a case is at the hearing level.

Unfortunately, most claims are initially denied (denied at the application level) and result in a claimant receiving a boilerplate notice of denial. What should be done once a notice of denial is received?

Continued at: Social Security Denial - What should be done if your disability is denied?

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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