Disability Associates discusses what medical evidence is required for Social Security disability.

The medical evidence required in a Social Security disability case can take many forms. From physician exams to mental health records, bloodwork panels, MRIs, CAT scans and X-rays, it’s safe to say that each case is unique. Providing timely and accurate medical evidence from your treating physician can greatly reduce or possibly eliminate the need for the Social Security Administration (SSA) to obtain additional medical evidence. Listed below are examples of items you may need for claiming benefits.

  1. Timely records: Records are considered timely if they are recent enough to be relevant to your current medical status. Depending on the disorder, your latest records can outline a simple medical ruling or finding. A condition that is rapidly changing requires more up-to-date information than one that is progressing slowly or has not changed for years. The SSA prefers records that are no older than six months, but keep in mind that old records may still be important depending on the medical condition.
  2. Sufficient medical records: Medical records should contain information from reliable medical sources to allow the SSA to make an independent medical decision regarding the nature and severity of the condition. For instance, it’s important to know that a person has cancer, but the records should also include comprehensive details about the ailment. Requested information includes:
  • Was there a biopsy completed to prove the cancer’s existence?
  • What kind of cancer is it?
  • Where is it in the body?
  • When did symptoms first start appearing?
  • What does the physical examination show?
  • What did x-rays or other imaging tests show?
  • Did the person have surgery?
  • Did it remove all of the cancer?
  • Did the person complete chemotherapy?
  • What were the side effects?
  • Did the person go through radiation therapy?
  • What were the results?

The SSA wants to see longitudinal records. They want detailed, specific medical information.

  1. Accurate records: All medical records should correctly describe your condition according to the standards of acceptable medical sources. A medical opinion that is countered by objective evidence will not be considered accurate. If your medical records list symptoms or issues, and you display something else, you run the risk of having rejected medical “proof.”

Overall, the best medical records are those that are typed, mention all complaints of the patient, show results of examination, note treatments that were given, responses to treatment and describe future plans with a prognosis.

For more information about whether your medical records are appropriate for a disability application, contact Disability Associates in Maryland today.