MEDICAL EVIDENCE OF RECORD Flashcards
LICENSED PHYSICIAN:
A licensed physician holds an M.D. degree with a valid license to practice medicine in the state in which they practice. Chiropractic, homeopathic and other alternative providers do not qualify.
TREATING SOURCE:
A treating source is a licensed physician or other licensed professionals responsible for delivering the claimant’s primary care.
TIMELINESS OF EVIDENCE:
In order for medical evidence to be properly used in a disability claim, it must be timely, accurate, and sufficient. The evidence is timely if it is dated around the time of the claimant’s period of disability. It is extremely helpful to the examiner and the ALJ if you list the actual dates of the medical evidence. The exact date of the evidence means the date the patient visited the medical source. The listing of medical evidence by date of visit creates a chronological flowchart.
When building the case, listing evidence by date also enables you to establish the impairment’s onset, duration, and progress.
Generally, SSA likes working with records no older than six months. That does not mean that older records are not important to the case. Records dating back for many years may help provide the big medical picture but are rarely used to make a recent decision.
THE ACCURACY OF EVIDENCE:
The accuracy of medical evidence is primarily about the focus of the evidence. Does the evidence directly address the impairment you are evaluating? If so, you are probably dealing with pertinent evidence.
SUFFICIENT MEDICAL EVIDENC:
This is a tricky one! To properly evaluate a claimant’s impairment, you must have enough data about the impairment to determine its limiting effects accurately. You are using the evidence to make an independen medical judgment regarding the nature and serferity ofthe claimant’s disorder.
INSUFFICIENT EVIDENCE:
You have inadequate evidence anytime that there is not enough evidence to establish onse, severity,k duration,k and the limitations to work caused by the impairment. A claimant must provide medical documentation proving that they have a total disability. The evidence must show that the claimant’s impairment is on the severity required to meet the disability standard. If there is not enough evidence available to make a decision, additional evidence will be needed in the form of further evidence or additional examinations.
BASIC REQUIRED EVIDENCE IN A SSDI CLAIM:
Please not that only evidence related to the claimant’s impairments are required. Here is a general list of evidence required by SSA to make a disability decision:
- Claimant’s medical history.
- Clinical findings, including the results of physical or mental status examinations.
- Clinical and laboratory results.
- X-ray, C-scan, MRI, etc.
- Primary doctor’s diagnosis and prognosis.
- Prescribed treatment regiment.
- The doctor’s opinion of the claimant’s ability to perform work.
- The doctor’s findings of ther claimant’s remaining functinal capabiities/
- Doctor’s opinion on claimant’s remaining ability to perform work-related activities,k such as sitting, standing, walking, lifting, carrying, handling objects, hearing, speaking, and traveling.
EVIDENCE IN MENTAL DISORDER, SSA NEEDS:
- Psychologist, psychiatrist exams
- Diagnosis and prognosis.
- Treatment regiment
- Response to treatment
- Detailed evaluation of the claimant’s remaining ability to understand, carry out, and remember instructions and respond appropriately to supervision, coworkers, and work pressures.
EVIDENCE FOR CHILD CASE:
Pretty much the same thing you would need in an SSDI case minus vocational data. You will need a description of a child’s cognitive capacity and remaining ability to perform age-appropriate activities.
INADEQUATE CONSUTATIVE EXAM:
If the claimant or his representative feels that they have not received an adequate consultative examination, contact the DDS examiner who arranged the exam. Tell the examiner why the exam was inadequate and await his decision on the issue.
DOCUMENTING SYMPTOMS:
In all disability claims, the representative needs to gather evidence of the claimant’s symptoms. The evidence must establish a diagnosis, contain supportive signs and descriptions of the claimant’s symptoms. Since symptoms over time. It is also essential to document a claimant’s symptoms:
- Location
- Frequency
- Duration
- Intensity
- Severity
- Pattern
Many symptoms have aggravating and relieving factors. That is, a claimant’s symptoms may be aggravated or worsened by the claimant’s movement, posture, or position. On the other hand, a claimant’s symptoms might be relieved by medication, exercise, position, or posture. All of this is relevant to determining if a claimant can perform some level of work.
NON-TRADITIONAL TREATMENTS:
If a claimant has an alleged impairment, that impairment must be diagnosed by a licensed physician. However, nothing is forcing a claimant to be treated by a licensed physician. For this reason, it is not common for a person to apply for disability benefits presenting with non-traditional medical sources.
Social Security will not consider medical evidence from any of these non-traditional sources. Requesting documentation from these individuals is usually a waste of time. However, depending upon the type of professional, you may be able to exact some activities of daily living or observed limitations data from the source. In any event, SSA will not base a final decision on this type of evidence.
