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What Your Doctor Should Include In A Report


Feel free to print this document and take it with you to your doctor

A necessary and important part of medical evidence supporting your claim is a detailed statement from your doctor(s), listing all of your symptoms and stating how these symptoms keep you from working. Don't assume your doctor(s) know what Social Security is looking for in this statement. What Social Security requires may be very different from what your doctor thinks of as "disability." It is also different from a "disability" for purposes of Workers' Compensation.

A Medical Report should be written like a consultation report the doctor would write for another doctor. In addition to the usual content, the report should explain how your condition affects your physical and/or mental activities, and particularly your ability to work.. Examples from your life would be very helpful.

When you ask for a medical report:

  • Consider asking the person on the medical team who has the most contact with you to write the report -- then ask the doctor to co-sign it. Physical therapists, nurses, and physicians' assistants may be more familiar than your doctor with your limitations and the way they effect on your ability to work and your daily life activities.
  • Give the doctor a worksheet of your daily activities and work activities that are impacted by your impairment. See Daily Activities and Work Activity Worksheets.
  • Print out the Social Security list of impairments for your condition. See offsite link. Give the list to the doctor so s/he can cite whatever symptoms you have in those terms if possible. Let the doctor know that Social security will look to see if you fit the list. If you don't then Social Security will look to see if your impairments are equivalent to those on the list.
  • Provide your primary physician with copies of all your completed Social Security forms so they will know what you have said so the forms can be consistent. Highlight the areas which contain the information you want the doctor to notice. His/her time is short. S/he will be more likely to look at this information if it doesn't require the time to read through an entire form.
  • Obtain and give to your doctor each of the following from other doctors, hospitals, clinics and therapists you have seen in connection with a condition which relates to your disability:
    • A copy of the medical record
    • Treatment notes
    • Test Reports
    • Hospital discharge summaries

Remind the doctor that this report is different from a report s/he would create if you were applying for Workers' Compensation.

Medical Reports for SSDI purposes should be based on a recent exam and should be focused on answering the following three questions which cover the elements in the Social Security definition of "disability." As noted above, if possible, the report should also include the impairments Social Security includes on the list about your health condition.

  1. What is the medically determinable impairment or combination of impairments?
  2. How does the impairment(s) significantly limit your physical and/or mental ability to perform substantial gainful work?
  3. Is the impairment expected to last for at period of at least 12 months, including any past period when you couldn't work, or result in death?

The Medical Report should include, in the following order:

  • Your medical history [(including your mental and nervous condition(s)]
  • Clinical findings (such as the results of physical or mental status examinations)
  • Laboratory findings (such as blood pressure, x-rays)
  • Diagnosis of each physical and mental condition. This is a statement of diseases or injuries based on their signs and symptoms.
  • Treatment prescribed for each condition, your response to the treatment, and prognosis (opinion about what is likely to happen to you because of your health condition.) The statement should include prescribed medications.
    • Keep in mind that any prognosis is about statistics -- not your situation. Statistics are about large numbers of people, and reflect the past rather than current practice. They do not necessarily predict the future of any individual.
  • A statement providing an opinion about what you can still do despite your impairment(s), based on the medical source's findings on the above factors. This statement should describe, but is not limited to:
    • Your ability to perform work-related activities in each of the following areas which apply to your work:
      • Physical Strength:
      • such as sitting, standing, walking, lifting, carrying, handling objects, hearing, speaking and traveling, in a work setting. The key is your ability to do these activities on a regular and continuing basis, which means 8 hours a day, 5 days a week, or a work schedule that is equal to this kind of schedule.
    • In cases of mental impairments, it should describe your ability to understand, to carry out and remember instructions, and to respond appropriately to supervision, co-workers and work pressures in a work setting.
    • Include even minor complaints. While they may not be disabling, they may prevent you from doing certain jobs -- especially in combination with other complaints.
    • If the opinion is based in whole in part on information you, your friends, relatives, counselors, or therapists provide, the doctor should explain they s/he thinks the information is to be believed. The explanation may be as simple as "The information from X seems credible because it is consistent with the diagnosis as well as the clinical findings."

Social Security, not the doctor determines whether you are "disabled" so there is no reason to ask the doctor to include his/her opinion. The doctor's report is only evidence about facts, which will be used in making the determination whether you're disabled for purposed of SSDI. Other factors will also be looked at to determine whether you're "disabled."

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