January 18, 2020

Why are Medical Records so Important in Your Social Security Disability Case?

Social Security defines disability in terms of how your closed head injury impacts your capacity to work. This includes the residual effects of your head injury to your physical capacity, your cognitive capacity, and your emotional stability.  SSA will also consider the side effects of any medications you take.

In a closed head injury case, you may be struggling with a variety of problems that could impact your capacity to work.  However, a Social Security judge will not simply accept your testimony or even the testimony of your spouse, relatives or friends.  Instead, the judge will want to see evidence of your limitations in your medical records.

Understand that physicians take detailed notes about your visits and treatments.  Every time you see the doctor, he/she will include in his/her office notes your complaints, how medications, physical or occupational therapy is working, whether you have been compliant with treatment and thoughts about what to do next.

If you are pursuing Social Security disability, it would be wise to speak with your doctor about functional limitations – this can include physical issues with sitting, standing, walking, lifting, carrying, bending, stooping, crouching and crawling.

You (and your family) should also discuss with your doctor cognitive and emotional issues – are you having difficulty focusing, remembering concentrating, behaving appropriately?  Are you easily fatigued? Experiencing seizures? Are you experiencing side effects with medications?

All of these issues would impact you in a work setting and if your doctor discusses these work activity limitations in your medical record, you are giving a disability judge the evidence he needs to approve your case.

Your doctor can also help your case by completing a functional capacity evaluation (using a form provided by your lawyer)  or by writing a narrative report that addresses your activity limitations.

Understand that your judge has to reach conclusions about your capacity to work even the easiest, low stress job.  Most judges look primarily at your medical records  to make their findings.  Your testimony can help a little (or it can hurt you a lot) but you are not going to win your case without a record of on-going medical treatment.