Medical Records

Although the primary issue in your Social Security disability case relates to your capacity for work, your medical treatment record will function as the main source of evidence used by the Social Security adjudicator or judge to evaluate your claim.  A claimant with significant work limitations but a very thin medical history can still win, but proceeding without a good medical record will be an uphill battle.

What, then, constitutes a convincing medical record in a Social Security case?  In my experience, Social Security looks for:

Definitive Diagnosis:   the medical education system in the United States trains physicians to diagnose and treat medical problems.  As such, most physicians in the U.S. are trained to categorize and label the medical problems experienced by their patients.

Many medical offices use a format called the S.O.A.P format – this acronym stands for:
o S – subjective
o O – objective
o A – assessment (often including a diagnosis)
o P – plan

For Social Security’s purposes, a firm diagnosis of your medical problems allows SSA employees to categorize your claim.  If you have an opportunity to review your medical records, look at what is written in the “assessment” space.

Social Security has incorporated specific medical diagnoses into the Listings published in the Code of Federal Regulations, so it is no surprise that a firm medical diagnosis is favored by Social Security personnel.

Sometimes, of course, a physician will not be able to make a definitive diagnosis.  Sometimes you will see terms like “etiology unknown” in a record or “rule out xyz” as the diagnosis.  In these cases it is helpful if your doctor will identify one or more of the possible diagnoses that may apply in your case even if he has not made any conclusions yet.

In cases without a firm diagnosis, you will have to overcome this unknown and hope that your doctor will cooperate and fill out a “functional capacity form.”

Longitudinal treatment record – the word “longitudinal” is a fancy synonym for “extensive and longstanding.”  Social Security judges like to see claimants with long and extensive medical files.  Fair or not (and Social Security is not supposed to punish claimants who cannot afford regular care).

Social Security judges seem to believe that a claimant who has been receiving regular treatment over many years is deserving of credit, especially if the treating doctor confirms over that time that the claimant’s symptoms are real and that the claimant is truly suffering.

There are no set rules, by the way, as to how much treatment is “enough.”  I would advise my clients that a doctor visit at least once every 3 to 4 months would be enough to constitute regular, on-going treatment.

Absence of any reference to “drug seeking behavior.”  Social Security has specific administrative policy that denies benefits to an otherwise disabled benefit if substance abuse is a “material contributing factor to that disability.

Absence of any reference to “malingering.”  The term “malingerer” refers to an individual who seeks treatment and/or drugs when there is no reasonable basis for such treatment.  Sometimes individual who seek treatment in the absence of an underlying medical problem may have diagnosed or diagnosed mental health problems.  Sometimes such individuals are claiming illness to avoid working.  In any case, if a physician suspects that you are malingering and that word ends up in your medical record, it tends to follow you and often can prejudice the opinion of subsequent physicians.

Compliance with medications and treatment – Social Security decision makers like to see claimants who comply fully with prescribed treatment.  This means that if a drug is prescribed, you need to take it regularly.  If physical therapy, smoking cessation, or a weight loss program is prescribed you need to make a concerted effort to follow your doctor’s directions.  Social Security does not penalize you if you refuse to undergo surgery or an experimental treatment.

If your medical record paints a picture of you as an individual who is fully compliant with your doctor’s prescriptions and treatment protocol and if it demonstrates that you are still experiencing significant limitations that would impact your capacity to work, your credibility will not be questioned and you will have a good chance at winning a favorable decision.