Social Security Disability – Understanding Your Medical Records

First and foremost, Social Security disability requires that a claimant meet the definition of “disabled” on a medical basis. The medical basis for a finding of disability is most often found in the medical records of the claimant, created by his treating physician(s). For that reason, it is important to understand what information is included in the medical records.

This does not mean that the claimant needs any medical training or experience reading medical records; it means that he needs to be aware of what he is are telling the doctor at each visit and how those conversations are being documented in the records. It also means understanding the diagnosed conditions and the names of the procedures undergone as treatment.

The easiest way to understand medical diagnoses and treatment is to talk to the doctor about them. Repeat the terminology the doctors use so that the condition and/or treatment can be properly documented on a Social Security application or when discussing the case with an attorney. This will also be beneficial when other providers ask questions about prior diagnoses and treatment.

Once a claimant understands the conditions and treatment, it is important to be aware of what he is reporting to the doctor. The more information shared with the physician, the better they can treat a patient and the more informative the medical records become. Instead of simply telling the doctor that he is “fine”, a claimant should discuss his symptoms in comparison to his previous visit. Is the pain worse, better or the same? Is it in the same spot and caused by the same activity or is there something new about the pain? If the visits are far apart (more than a few weeks), it may be beneficial to keep a journal and document when something new or different occurs related to the symptoms.

Finally, a claimant may request his own medical records. While some providers charge patients for the records, the records will show the claimant exactly what the physician is documenting, even if only a few visit dates are requested. If a claimant feels that the records are not a true reflection of his complaints, he can begin the conversation with his doctor about his social security application and the option for including more specific information in the records. These small steps may also save a claimant’s attorney from having to contact the doctor to ask for a more complete description of a claimant’s treatment and prognosis.


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