Social Security does not require you to have any past medical history in order for you to file for disability benefits (under SSDI, social security disability insurance or SSI, supplemental security income). However, disability examiners prefer to have past medical treatment records to make their disability decisions. If you have been treated for your disabling condition in the past, your treating physician’s notes (i.e. your personal doctor’s notes) often offer a perspective that is not available otherwise.

 

For instance, hospital treatment notes generally do not include information about your limitations or your response to various treatment methods. Hospital records generally provide useful objective medical evidence (i.e. various imaging results, lab tests, etc.) and acute medical treatment records, but they do not tell the examiner much about the ongoing severity of your disabling condition or how these limitations might prevent you working enough to be self supporting.

The key to winning SSDI or SSI disability benefits from the Social Security Administration is having an impairment that so severely limits your ability to function; that is, it prevents you from doing ordinary daily activities such as work, shopping, household chores, paying bills, driving, etc. Past or old medical records can provide useful information as to how debilitating your medical impairment has been over the course of time.

What does a disability examiner (or an administrative law judge if your case is at the hearing level) look for in your medical records? Disability examiners look for objective medical evidence to support your allegation of a severe physical or mental impairment. Objective evidence might be imaging results (MRI, cat scan, x-ray, etc.), blood work, breathing tests, counseling notes, or any other evidence used to diagnose and treat various disabling impairments.

Disability examiners can only consider medical evidence from acceptable medical sources. Licensed or certified medical professionals such as physicians, psychiatrists, psychologists, podiatrists, speech therapists, etc. are considered acceptable medical sources by Social Security. Currently, chiropractors are not considered an acceptable medical source by Social Security. However, disability examiners can use any objective medical testing results (usually, this means xrays) contained in their records for their medical disability decision.

What if you have no current medical records? There is no way for a disability examiner to make a decision on a claim without current medical records. If you have no medical records, or just no current medical records (meaning no older than three months), you will most likely be scheduled for a consultative examination, CE for short.

Social Security pays independent medical professionals to perform these short basic physical or mental consultative exams. These exams are not likely to give a true picture of a person’s limitations and are performed strictly for the purpose of giving the disability examiner some current medical information to make their disability determination.

Article via SSDRC