Why is medical evidence crucial to your patient's claim?
Medical records are very important to pursue a claim for Social Security Disability benefits. Records provide a chronological account of the diagnosis, treatment, and progression of your patient’s condition over time.
These documents are crucial for painting a comprehensive picture of how your patient's condition impacts their daily life and ability to work. Without this evidence, establishing the severity of their condition to the Social Security Administration (SSA) becomes nearly impossible.
SSA looks for inconsistencies or gaps in medical evidence to justify their denials. When your patient submits a well-documented medical record, it makes it more difficult for SSA to deny their claim.
How much detail do my patient’s medical records need to contain?
The more detailed your records, the better position your patient is in while pursuing their claim. A record that simply states a diagnosis without detailing the range of symptoms, their severity, and their impact on your patient’s work and daily activities will not provide a strong foundation for their claim. Comprehensive records will include diagnostic tests, treatments, medications, and notes on how your patient’s condition is progressing or deteriorating. The more detailed the record, the more compelling your patient’s case becomes.
Incomplete or ambiguous medical records are a claimant’s worst enemy. Any inconsistencies, gaps, or ambiguities allow SSA to reject your patient’s claim. Ambiguities allow SSA to point to the records to say they are inconsistent with your patient's statements about how their condition affects their functioning, giving SSA a good reason to deny the claim.
What medical documentation can support your patient’s claim?
Medical documentation that can support your patient’s SSD claim include:
Diagnostic Tests: One of the most useful pieces of evidence are objective tests such as X-rays, MRIs, CT scans, or other testing appropriate to the condition.
Symptoms Documentation: Your patient’s medical records must document the symptoms they experience, no matter how trivial they may seem. It is also important to document changes in the condition, response to prescribed treatment, and the efficacy or side effects of medication. The more consistent your notes are with the objective evidence the better position your patient will be in.
Ongoing Evaluations: Your patient needs to continue to be treated even if their condition hasn’t changed.
Updates and Addenda to Medical Records: Doctors should think of medical records as living documents that require constant updating. Every change in medication, every new symptom, and every incremental result from diagnostic tests should be promptly recorded at each visit. Such updates can show that your patient's condition has not improved.
The Importance of a Medical Source Statement
While medical records are a crucial part of your patient's disability claim, a Medical Source Statement is equally important. A Medical Source Statement must set forth the diagnosis, symptoms, treatment history, and the limitations your patient's condition imposes on them. You may offer your opinion in a narrative letter as well.
It is important to note that Social Security considers what a person can do in a regular 40-hour work week on an ongoing basis. SSA is looking for your opinion based on your examinations and treatment of your patient.
A Functional Capacity Evaluation (FCE) is not necessary and is cost-prohibitive for most people.
Let’s work together to help your patient.
Doctors play an important role in the SSD claims process. From diagnosis and thorough documentation to specialized evaluations as appropriate, a healthcare provider’s comprehensive and accurate input can be a patient’s greatest ally in securing the benefits they need and deserve.
If you have a patient who is suffering from an injury or condition that prevents them from working, the process of applying for Social Security Disability benefits can be complicated, and going through it alone is not the only option.
At MCV Law, our experienced disability attorneys understand the application process and the type of evidence needed to support a claim. Whether your patient is applying for disability or appealing a denial, our dedicated team is here to assist every step of the way.