When applying for disability claims, you must prove you have a serious medical condition. What affects your functional capabilities? SSA will request comprehensive medical records to determine eligibility. Your documentation should include reports from specialists and other healthcare providers (tangible evidence on imaging studies, lab tests, etc.). Strong medical records show the severity of your condition.Â
Understanding Medical Records
Medical records track your history over time – they also show your current health status. The essential components to look out for are:
- Basic information about the patient
- History of the present condition
- Findings on physical examination
- Diagnostic results-imaging, lab tests, etc.
- Clinical diagnosis
- Progress notes and follow-up plan
- Consultation reports
- Discharge summary and billing information
Types of records needed for a disability claim
- Diagnostic records and specialist reports
- Functional capacity evaluations
- Current treatment plan and future treatment recommendations
- Statements from other healthcare providers
- Records of work history
- Previous disability claims
- Financial documentation
How Strong Medical Records Support Your Claim
To ensure your medical condition is legitimate, you should provide evidence of diagnosis and treatment. The process starts with organizing your medical records. Prepare reports on CT scans, MRIs, and X-rays. You also need to include reports on physical therapies and surgeries. Above all, having an expert to guide you through the process is invaluable.
A competent social security disability attorney in California for example, will request a statement from your healthcare provider showing a summary of your treatment history. Furthermore, he will document the impact of your condition – how it affects your work performance. If you were referred to specialists, he will help you gather reports from consultations.
The key to successful approval is demonstrating the severity of your condition. If you have a spinal injury, the imaging studies will show the extent of the damage. Another way to prove the severity of the condition is by demonstrating the medication did not alleviate the symptoms.
Work-related limitations can also prove that you’re unable to carry out physical activities like standing, lifting, etc. However, you need a certified medical report to support your claim.
Common Issues with Medical Records
If your medical records have issues, they may not support the credibility of your claim. As such, you should ensure the report covers the various aspects of your condition. Inaccuracies and outdated information can also lead to denials. Therefore, you should fill in the missing gaps and inconsistencies.
Some healthcare providers may slow down the production of records due to the high volume of claims. Failure to submit the requested documents on time could further delay the process. Plus, sometimes, the medical records may contain descriptions that don’t show the impact of the condition. Failure to address them on time could signal a breakdown in communication.
Tips for Ensuring Strong Medical Records
Strong medical records exhibit the severity of your condition. Here are some tips to show the legitimacy of your condition:
Keeping detailed and organized records
Ensure the treatments are well reflected. Request for treatment plans, diagnosis, and functional assessments. Next, review and verify the records for discrepancies.
Regularly updating records and obtaining new documentation
Ask your healthcare provider to address potential issues about your condition and provide new documentation. To ensure the accuracy of the information, you should get in touch with your healthcare providers. Establish a clear channel of communication and set guidelines on the forms required. If there are changes in your condition, inform them on time.
Conclusion
Strong medical records will not only validate the severity of your condition but also show it has been monitored over time. They also reveal you can’t perform work-related tasks. This is what SSA requires to process your claim. You should maintain and utilize your medical records effectively to reduce the chances of denials.
