Attorneys representing disability claimants will need solid medical evidence to support the disability allegation. This evidence is to be developed from the medical records through a thorough medical chart review. Attorneys requesting medical record review for disability should therefore have a clear understanding of the medical records that are required in each case. This blog highlights some important tips attorneys can consider when preparing to request and review the plaintiff’s medical records.
The most important evidence required is the statement or opinion from the plaintiff’s treating physicians. The contact information of these doctors must be obtained from the plaintiff so that the lawyer can request the doctors to submit a written statement or opinion of the plaintiff’s diagnosis, prognosis, and functional limitations in a residual functional capacity (RFC) statement. Attorneys need to ensure that they have a complete medical history of their client, which should include the names and contact details of all treating physicians, dates and locations of medical tests, dates and locations of hospitalizations, complete medication list including dosage, prescribing physicians’ names, and documented side effect, if any.
The attorney must make sure that the plaintiff’s disability meets one of the disability listings in the SSA (Social Security Administration)’s Blue Book. The treating physician must have documented that the disability prevents the claimant from engaging in substantial gainful activity, which is an important consideration for the SSA.
Let us look at the medical documentation sources the SSA considers reliable for medical record analysis to determine disability.
- Licensed physicians
- Physicians’ assistants
- Advanced registered nurse practitioners
- Licensed podiatrists
- Nurse licensed optometrists
- Licensed/certified psychologists
- Qualified speech-language pathologists
- Hospitals where the plaintiff received treatment
As a medical review company well-versed in reviewing medical records for social security disability claims, we understand that the following medical reports and records are very important.
- Medical history
- Diagnostic records
- Clinical exams/tests results
- Lab findings, X-rays, CT scans, MRI scans
- Diagnosis of disabling condition
- Treatments prescribed, and the plaintiff’s response to the treatment, prognosis
- A statement from the treating physician regarding what the plaintiff is still able to do in spite of the disability, based on the medical findings. Information regarding the claimant’s work-related mental ability, and work-related physical ability should be included.
- Medical records demonstrating the plaintiff’s symptoms such as pain and fatigue that affect his/her ability to function
The medical documentation must be accurate, complete and reliable. The medical records must be recent enough or timely to be relevant to the plaintiff’s current medical condition – the SSA prefers medical records no older than six months. However, older medical records are also relevant because they help provide a broader view of the plaintiff’s medical condition. The medical records must contain sufficient medical information from acceptable medical sources that provide a clear view of the nature and severity of the plaintiff’s disability or impairment.
It is best that the attorney requests detailed opinions from treating doctors with whom the plaintiff has had a long relationship. Besides, detailed opinions are best obtained only from doctors who are specialists in diagnosing and treating the claimant’s medical condition. The doctor’s opinion must be supported by objective medical evidence that is consistent with other information in the medical chart.
Given the importance of relevant medical records, an attorney can save time and effort by hiring the services of a medical chart review company. This company can review the hundreds of pages of medical documentation to identify the relevant ones and submit only those to the SSA. This will speed up the claim processing by providing clarity regarding the plaintiff’s actual disability and how it affects his or her life and the ability to perform work.
