Medical Records Enhance your Disability Case

Simply put, the more medical evidence available to back up your claim for disability, the better your chances of getting an early decision (or a favorable decision at all).

In most Social Security disability cases, your medical record carries heavy weight, even though the primary factor is your ability to work. Your medical record is a major piece of evidence that the judge and medical expert will use to base their testimony and decisions on. A claimant with severe work limitations but with a weak medical record can still win, it is just much more difficult without good medical records.

You may be wondering what a solid medical record would look like. Here are some trademarks of good medical evidence:

1.) A definitive diagnosis. Doctors in the United States are trained to diagnose and treat medical problems.  A definitive diagnosis is powerful evidence. Almost all physicians can categorize and label their patients’ medical issues. The SOAP format is an often used acronym, which means subjective, objective, assessment (including a diagnosis), and plan. A positive medical diagnosis lets Social Security workers categorize your disability claim. If you have accessed your medical records, check the “assessment” space for what the doctor has said about your condition.

The Social Security Administration prefers to have a definite diagnosis because they have published listings in the Code of Federal Regulations, which consist of specific medical diagnoses.

There are cases where the physician will be incapable of making a definitive diagnosis. When this happens, the doctor may put “etiology unknown” or “rule out xyz” instead of a detailed diagnosis. For your case, it would be better if the doctor listed one or more possible diagnoses, even if he or she was not positive. If your doctor cannot provide a definite diagnosis, then you will have to overcome this unknown. If this is the case, then at least hopefully your physician will fill out a functional capacity form – which acknowledges specific limitations.

2. A longitudinal treatment record basically means an extensive and longstanding record. An extensive medical file will dispose a judge in your favor. Although it does not seem fair, the Social Security Administration’s policy is to make it hard for claimants who cannot afford medical care to receive benefits. If a claimant has been going to a physician for treatment for years, then the SSA feels that the claimant deserves benefits. This is particularly true if the treating doctor testifies that the patient’s condition is real.

Unfortunately, there are no set guidelines as to what constitutes regular doctor treatments. Attending a physician a minimum of once every three or four months would qualify as on-going medical treatment.

3. Lack of any reference to “drug seeking behavior.” There should be no record of drug abuse. A specific policy of the Social Security Administrations declares that a claimant cannot receive disability benefits if substance abuse contributed to the condition.

4. Lack of any reference to “malingering.” There also can be no reference that the claimant has tried to malinger. A malingerer is someone who seeks drugs or other medication for a condition without any basis for obtaining those medications. This may be because the claimant is trying to avoid working or has mental health problems. Whatever the reason, if a physician writes suspicion of malingering on your medical record, it could prejudice other doctors against you.

5. Compliance with medications and treatment. In order to gain the approval of Social Security workers, you should follow your prescribed treatment. This means taking your medicine every time you are supposed to. It can also mean that if your doctor orders you to, you need to stop smoking or lose weight. It will not adversely affect your claim if you do not undergo surgery or a type of experimental treatment.

You will have a much better chance of winning your hearing if your medical record shows you to be someone who follows your doctor’s prescriptions, is credible, and is experiencing severe limitations.

6. Form Filled out by Your Doctor. If possible, make sure that you ask your physician to support your claim by placing your limitations in a letter, a narrative report, or even a checklist form.  See if your physician can “translate” your medical issues into more specific work limitations.  This way, you’re giving Social Security exactly what they want to see, and your chances of getting an early decision are that much better.