Importance of Medical Documentation for SSDI

Applying for Social Security Disability Insurance (SSDI) can be a complicated, drawn-out process, with many applications rejected initially. If you’re in a position where your condition is preventing you from working, SSDI can be crucial to maintaining a source of stable income. Medical records provide a foundation for your SSI disability application – they not only help move the process along but can increase your chances at qualifying for benefits.

Medical Evidence Fundamentals

For medical records to be considered by the Social Security Administration (SSA), they need to be 3 things: up-to-date, accurate, and adequately detailed.
SSI disability application

Up-to-Date: Any medical evidence should be recent, typically no older than 6 months, although older “longitudinal” records are still very important. It’s also crucial to consider the amount of time it may take medical specialists to sign off on any documentation needed for a claim and plan accordingly so that you have this paperwork in advance. If SSA officials don’t have medical evidence needed, your claim may be denied.

Accurate: Make sure your medical records are all consistent and appropriately describe your condition. Any evidence that is considered inaccurate will not be considered for your claim.

Detailed: The more thorough your records are, the better. Any medical evidence should have enough accurate information for the SSA to determine a conclusion about your conditions and limitations. It’s also possible that you’ll be asked to attend an exam with an appointed medical specialist.

Keeping your medical documentation organized is central to proceed with a disability claim. If you get stuck or need guidance with the process, a social security disability lawyer can help acquire the appropriate records needed.

Types of Medical Evidence

The SSA uses criteria called the “Blue Book” in order to determine whether someone’s impairment qualifies for disability benefits. The medical records and information you provide can depend if your condition is listed in the Blue Book.

There are several types of evidence that can be needed to help you qualify for benefits:

Objective Medical Evidence

This includes official clinical and laboratory findings, such as blood tests or MRIs. In many instances, the SSA will require any treating medical specialists to provide reporting on your condition.

  • Diagnosis and/or prognosis of a condition
  • Any treatments prescribed, including therapy, medication, or surgery
  • Test results related to the condition
  • Medical history before disability
  • Documented complications caused by disability
  • Emergency room visit logs

Professional Medical Opinion

This is an official statement from your medical provider that details your abilities and limitations related to your condition.

  • Statements from medical specialists or physicians
  • Historical evidence of continuing condition limitations from provider visits

Evidence of Limitations

This includes evidence from non-medical sources, such as statements from family members, employers or co-workers who have witnessed firsthand any limitations you may have experienced from your condition.

  • Any symptoms that affect your ability to function
  • Triggering factors for symptoms
  • Limitations on normal daily activities
  • Frequency of symptoms
  • How medications you take help manage symptoms

The more relevant medical information you can provide, the better your chances are of being approved.

Sufficient Medical Sources

Any medical documentation submitted to the SSA is regulated to ensure it came from a professional medical source. Some verified licensed medical sources include:

  • Primary Care Physicians
  • Physician Specialists
  • Psychologists
  • Speech & Language Pathologists
  • Podiatrists
  • Optometrists

Medical documentation is not considered by the SSA until it’s deemed valid, so it’s important to make sure this gets taken care of and keep your claims process moving.

Disability Attorneys at Woodruff & Mathis

At Woodruff & Mathis, we have more than 20 years of experience representing over 1,500 clients with their SSDI claims. We understand the importance of having a sufficient collection of the above medical records to help increase your chances of approval and will work with you through each step when filing for benefits.

Let the team at Woodruff & Mathis assist you with your SSI disability application. Contact us today to schedule your appointment!