Medical Documentation for Your Social Security Disability (ssdi) Case

Under both the Title II and Title XVI programs, medical evidence is the cornerstone for the determination of disability.  Each person who files a disability claim is responsible for providing medical evidence showing that he or she has an impairment(s) and how severe the impairment(s) may be.   However, the Social Security Administration (SSA) will help claimants get medical reports from their own medical sources when the claimants give SSA permission to do so. This medical evidence generally comes from sources who have treated or evaluated the claimant for his or her impairment(s). 

Acceptable Medical Sources

Documentation of the existence of a claimant’s impairment must come from medical professionals defined by SSA regulations as “acceptable medical sources.”  Once the existence of an impairment is established, all the medical and non-medical evidence is considered in assessing impairment severity. ”Acceptable medical sources” are:

• licensed physicians (medical or osteopathic doctors); 

• licensed or certified psychologists. Included are school psychologists, or other licensed or certified individuals with other titles who perform the same function as a school psychologist in a school setting, for purposes of establishing mental retardation, learning disabilities, and borderline intellectual functioning only ;

• licensed optometrists, for purposes of establishing visual disorders only (except, in the U.S. Virgin Islands, licensed optometrists, for the measurement of visual acuity and visual fields only);

• licensed podiatrists, for purposes of establishing impairments of the foot, or foot and ankle, depending on whether the State in which the podiatrist practices permits the practice of podiatry on the foot only, or the foot and ankle; and

• qualified speech-language pathologists, for purposes of establishing speech or language impairments only. For this source, “qualified” means that the speech-language pathologist must be licensed by the State professional licensing agency, or be fully certified by the State education agency in the State in which he or she practices, or hold a Certificate of Clinical Competence from the American Speech-Language-Hearing Association.

Medical Evidence from Treating Sources

Currently, many disability claims are decided on the basis of medical evidence from treating sources. SSA regulations place special emphasis on evidence from treating sources because they are likely to be the medical professionals most able to provide a detailed longitudinal picture of the claimant’s impairments and may bring a unique perspective to the medical evidence that cannot be obtained from the medical findings alone or from reports of individual examinations or brief hospitalizations. Therefore, timely, accurate, and adequate medical reports from treating sources accelerate the processing of the claim because they can greatly reduce or eliminate the need for additional medical evidence to complete the claim.

Medical Evidence From Health Facilities

Social Security also requests copies of medical evidence from hospitals, clinics, or other health facilities where a claimant has been treated. All medical reports received are considered during the disability determination process.

Other Evidence

Information from other sources may also help show the extent to which a person’s impairment(s) affects his or her ability to function in a work setting; or in the case of a child, the ability to function compared to that of children the same age who do not have impairments. Other sources include public and private agencies, non?medical sources such as schools, parents and caregivers, social workers and employers, and other practitioners such as naturopaths, chiropractors, and audiologists.

Medical Reports

Physicians, psychologists, and other health professionals are frequently asked by SSA to submit reports about an individual’s impairment. Therefore, it is important to know what evidence SSA needs. Medical reports should include:

• medical history;

• clinical findings (such as the results of physical or mental status examinations);

• laboratory findings (such as blood pressure, x-rays);

• diagnosis;

• treatment prescribed with response and prognosis;

• a statement providing an opinion about what the claimant can still do despite his or her impairment(s), based on the medical source’s findings on the above factors. This statement should describe, but is not limited to, the individual’s ability to perform work-related activities, such as sitting, standing, walking, lifting, carrying, handling objects, hearing, speaking, and traveling. In cases involving mental impairments, it should describe the individual’s ability to understand, to carry out and remember instructions, and to respond appropriately to supervision, coworkers, and work pressures in a work setting. For a child, the statement should describe his or her functional limitations in learning, motor functioning, performing self-care activities, communicating, socializing, and completing tasks (and, if a child is a newborn or young infant from birth to age 1, responsiveness to stimuli).

 Consultative Examinations

If the evidence provided by the claimant’s own medical sources is inadequate to determine if he or she is disabled, additional medical information may be sought by recontacting the treating source for additional information or clarification, or by arranging for a CE. The treating source is the preferred source for a CE if he or she is qualified, equipped, and willing to perform the examination for the authorized fee. Even if only a supplemental test is required, the treating source is ordinarily the preferred source for this service. However, SSA’s rules provide for using an independent source (other than the treating source) for a CE or diagnostic study if:

• the treating source prefers not to perform the examination;

• the treating source does not have the equipment to provide the specific data needed;

• there are conflicts or inconsistencies in the file that cannot be resolved by going back to the treating source;

• the claimant prefers another source and has good reason for doing so; or prior experience indicates that the treating source may not be a productive source.

 Consultative Examination Report Content

A complete CE is one which involves all the elements of a standard examination in the applicable medical specialty. A complete consultative examination report should include the following elements:

• the claimant’s major or chief complaint(s); 

• a detailed description, within the area of specialty of the examination, of the history of the major complaint(s); 

• a description, and disposition, of pertinent “positive” and “negative” detailed findings based on the history, examination, and laboratory tests related to the major complaint(s), and any other abnormalities or lack thereof reported or found during examination or laboratory testing;

• results of laboratory and other tests (e.g., X-rays) performed according to the requirements stated in the Listing of Impairments; 

• the diagnosis and prognosis for the claimant’s impairment(s); 

• a statement about what the claimant can still do despite his or her impairment(s), unless the claim is based on statutory blindness. This statement should describe the opinion of the consultant about the claimant’s ability, despite his or her impairment(s), to do work related activities such as sitting, standing, walking, lifting, carrying, handling objects, hearing, speaking, and traveling; and, in cases of mental impairment(s), the opinion of the consultant about the individual’s ability to understand, to carry out and remember instructions, and to respond appropriately to supervision, coworkers, and work pressures in a work setting. For a child, the statement should describe the child’s functional limitations in learning, motor functioning, performing self-care activities, communicating, socializing, and completing tasks (and, if the child is a newborn or young infant from birth to age 1, responsiveness to stimuli); and

• the consultant ’s consideration, and some explanation or comment on, the claimant’s major complaint(s) and any other abnormalities found during the history and examination or reported from the laboratory tests. The history, examination, evaluation of laboratory test results, and the conclusions will represent the information provided by the consultant who signs the report.

 Evidence Relating to Symptoms

In developing evidence of the effects of symptoms, such as pain, shortness of breath, or fatigue, on a claimant’s ability to function, SSA investigates all avenues presented that relate to the complaints. These include information provided by treating and other sources regarding:

• the claimant’s daily activities;

• the location, duration, frequency, and intensity of the pain or other symptom;

• precipitating and aggravating factors;

• the type, dosage, effectiveness, and side effects of any medication;

• treatments, other than medications, for the relief of pain or other symptoms;

• any measures the claimant uses or has used to relieve pain or other symptoms; and

• other factors concerning the claimant’s functional limitations due to pain or other symptoms.

 In assessing the claimant’s pain or other symptoms, the decision maker must give full consideration to all of the above-mentioned factors. It is important that medical sources address these factors in the reports they provide.