Medical Documentation for Your Social Security Disability (ssdi) Case

Under both the Title II and Title XVI programs,birth to age 1, responsiveness to stimuli).
medical evidence is the cornerstone for the 
determination of disability.  Each person who files 
a disability claim is responsible for providing medical Consultative Examinations
evidence showing that he or she has anIf the evidence provided by the claimant’s
impairment(s) and how severe the impairment(s)own medical sources is inadequate to determine if
may be.   However, the Social Securityhe or she is disabled, additional medical information
Administration (SSA) will help claimants getmay be sought by recontacting the treating
medical reports from their own medical sourcessource for additional information or clarification, or
when the claimants give SSA permission to do so.by arranging for a CE. The treating source is the
This medical evidence generally comes frompreferred source for a CE if he or she is qualified,
sources who have treated or evaluated theequipped, and willing to perform the examination
claimant for his or her impairment(s). for the authorized fee. Even if only a supplemental
Acceptable Medical Sourcestest is required, the treating source is ordinarily
Documentation of the existence of athe preferred source for this service. However,
claimant’s impairment must come fromSSA’s rules provide for using an independent
medical professionals defined by SSA regulationssource (other than the treating source) for a CE
as “acceptable medical sources.”  Onceor diagnostic study if:
the existence of an impairment is established, all- the treating source prefers not to perform the
the medical and non-medical evidence isexamination;
considered in assessing impairment severity. 
”Acceptable medical sources” are: 
- licensed physicians (medical or osteopathic- the treating source does not have the
doctors); equipment to provide the specific data needed;
  
  
- licensed or certified psychologists. Included are- there are conflicts or inconsistencies in the file
school psychologists, or other licensed or certifiedthat cannot be resolved by going back to the
individuals with other titles who perform the sametreating source;
function as a school psychologist in a school 
setting, for purposes of establishing mental 
retardation, learning disabilities, and borderline- the claimant prefers another source and has
intellectual functioning only ;good reason for doing so; or prior experience
 indicates that the treating source may not be a
 productive source.
- licensed optometrists, for purposes of 
establishing visual disorders only (except, in the 
U.S. Virgin Islands, licensed optometrists, for the Consultative Examination Report Content
measurement of visual acuity and visual fieldsA complete CE is one which involves all the
only);elements of a standard examination in the
 applicable medical specialty. A complete
 consultative examination report should include the
- licensed podiatrists, for purposes of establishingfollowing elements:
impairments of the foot, or foot and ankle,- the claimant’s major or chief complaint(s); 
depending on whether the State in which the 
podiatrist practices permits the practice of 
podiatry on the foot only, or the foot and ankle;- a detailed description, within the area of specialty
andof the examination, of the history of the major
 complaint(s); 
  
- qualified speech-language pathologists, for 
purposes of establishing speech or language- a description, and disposition, of pertinent
impairments only. For this source,“positive” and “negative” detailed
“qualified” means that the speech-languagefindings based on the history, examination, and
pathologist must be licensed by the Statelaboratory tests related to the major complaint(s),
professional licensing agency, or be fully certifiedand any other abnormalities or lack thereof
by the State education agency in the State inreported or found during examination or
which he or she practices, or hold a Certificate oflaboratory testing;
Clinical Competence from the American 
Speech-Language-Hearing Association. 
 - results of laboratory and other tests (e.g.,
 X-rays) performed according to the requirements
Medical Evidence from Treating Sourcesstated in the Listing of Impairments; 
Currently, many disability claims are decided on 
the basis of medical evidence from treating 
sources. SSA regulations place special emphasis on- the diagnosis and prognosis for the
evidence from treating sources because they areclaimant’s impairment(s); 
likely to be the medical professionals most able to 
provide a detailed longitudinal picture of the 
claimant’s impairments and may bring a- a statement about what the claimant can still do
unique perspective to the medical evidence thatdespite his or her impairment(s), unless the claim
cannot be obtained from the medical findingsis based on statutory blindness. This statement
alone or from reports of individual examinations orshould describe the opinion of the consultant about
brief hospitalizations. Therefore, timely, accurate,the claimant’s ability, despite his or her
and adequate medical reports from treatingimpairment(s), to do work related activities such
sources accelerate the processing of the claimas sitting, standing, walking, lifting, carrying, handling
because they can greatly reduce or eliminate theobjects, hearing, speaking, and traveling; and, in
need for additional medical evidence to completecases of mental impairment(s), the opinion of the
the claim.consultant about the individual’s ability to
Medical Evidence From Health Facilitiesunderstand, to carry out and remember
Social Security also requests copies of medicalinstructions, and to respond appropriately to
evidence from hospitals, clinics, or other healthsupervision, coworkers, and work pressures in a
facilities where a claimant has been treated. Allwork setting. For a child, the statement should
medical reports received are considered duringdescribe the child’s functional limitations in
the disability determination process.learning, motor functioning, performing self-care
Other Evidenceactivities, communicating, socializing, and
Information from other sources may also helpcompleting tasks (and, if the child is a newborn or
show the extent to which a person’syoung infant from birth to age 1, responsiveness
impairment(s) affects his or her ability to functionto stimuli); and
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- the consultant ’s consideration, and some
sources include public and private agencies,explanation or comment on, the claimant’s
non?medical sources such as schools, parents andmajor complaint(s) and any other abnormalities
caregivers, social workers and employers, andfound during the history and examination or
other practitioners such as naturopaths,reported from the laboratory tests. The history,
chiropractors, and audiologists.examination, evaluation of laboratory test results,
Medical Reportsand the conclusions will represent the information
Physicians, psychologists, and other healthprovided by the consultant who signs the report.
professionals are frequently asked by SSA to 
submit reports about an individual’s 
impairment. Therefore, it is important to know Evidence Relating to Symptoms
what evidence SSA needs. Medical reports shouldIn developing evidence of the effects of
include:symptoms, such as pain, shortness of breath, or
- medical history;fatigue, on a claimant’s ability to function,
 SSA investigates all avenues presented that relate
 to the complaints. These include information
- clinical findings (such as the results of physical orprovided by treating and other sources regarding:
mental status examinations);- the claimant’s daily activities;
  
  
- laboratory findings (such as blood pressure,- the location, duration, frequency, and intensity of
x-rays);the pain or other symptom;
  
  
- diagnosis;- precipitating and aggravating factors;
  
  
- treatment prescribed with response and- the type, dosage, effectiveness, and side
prognosis;effects of any medication;
  
  
- a statement providing an opinion about what the- treatments, other than medications, for the
claimant can still do despite his or herrelief of pain or other symptoms;
impairment(s), based on the medical source’s 
findings on the above factors. This statement 
should describe, but is not limited to, the- any measures the claimant uses or has used to
individual’s ability to perform work-relatedrelieve pain or other symptoms; and
activities, such as sitting, standing, walking, lifting, 
carrying, handling objects, hearing, speaking, and 
traveling. In cases involving mental impairments, it- other factors concerning the claimant’s
should describe the individual’s ability tofunctional limitations due to pain or other
understand, to carry out and remembersymptoms.
instructions, and to respond appropriately to 
supervision, coworkers, and work pressures in a 
work setting. For a child, the statement should In assessing the claimant’s pain or other
describe his or her functional limitations in learning,symptoms, the decision maker must give full
motor functioning, performing self-care activities,consideration to all of the above-mentioned
communicating, socializing, and completing tasksfactors. It is important that medical sources
(and, if a child is a newborn or young infant fromaddress these factors in the reports they provide.