The Importance of Medical Records in Social Security Disability Claims

Welcome to Season 1, Episode 30 of Winning Isn't Easy: Navigating Your Social Security Disability Claim. In this episode, we'll dive into the complicated topic of "The Importance of Medical Records in Social Security Disability Claims."

When it comes to Social Security Disability, your medical records aren’t just paperwork - they’re the foundation of your entire claim. You might think your diagnosis, your pain, or your daily struggles speak for themselves, but without detailed and consistent medical documentation, the SSA won’t see the full picture. And without that evidence, even the strongest claim can crumble. In this episode of Winning Isn’t Easy, host Nancy L. Cavey breaks down why medical records are the single most important factor in getting your claim approved. She explains what the SSA is really looking for in your file, how vague or incomplete notes can lead to denial, and why the right providers and consistent treatment are key. Nancy also takes you inside the SSA’s electronic records system - how it works, where it fails, and what you can do to make sure your story doesn’t get lost in the shuffle. Whether you’re filing for the first time or waiting on a decision, this episode gives you the tools to take control of your medical evidence. Because at the end of the day, your story matters - but only if it’s written down in the record.

In this episode, we'll cover the following topics:

One - Why Medical Records Matter So Much in Your Social Security Disability Claim

Two - How to Gather and Submit the Right Medical Evidence

Three - What Every Social Security Disability Applicant Needs to Know About the Social Security Administration’s Electronic Record Retrieval System

Whether you're a claimant, or simply seeking valuable insights into the disability claims landscape, this episode provides essential guidance to help you succeed in your journey. Don't miss it.


Listen to Our Sister Podcast:

We have a sister podcast - Winning Isn't Easy: Long-Term Disability ERISA Claims. Give it a listen: https://wiedisabilitypodcast.buzzsprout.com


Resources Mentioned In This Episode:

LINK TO YOUR RIGHTS TO SOCIAL SECURITY DISABILITY: https://mailchi.mp/caveylaw/your-rights-to-social-security-disability-benefits

FREE CONSULT LINK: https://caveylaw.com/contact-us/


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Need help with your Social Security Disability claim? Have questions? Please feel welcome to reach out to use for a FREE consultation. Just mention you listened to our podcast.

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Please remember that the content shared is for informational purposes only, and should not replace personalized legal advice or guidance from qualified professionals.

Transcript

Speaker A [00:00:11]:
 Welcome back to Winning Isn't Easy, Social Security Disability Benefits, the podcast where we break down everything you need to know about navigating the Social Security disability claims process. I'm your host, Nancy Cavey. Before we get started, I've got to give you a legal disclaimer. This podcast is not legal advice. The Florida Bar association says that I have to tell you this. And now that I've told you that this podcast isn't legal advice, nothing will prevent me from giving you an easy to understand overview of the Social Security disability claims process, the games that are played, and what you need to know to get the disability benefits you deserve. So off we go. Now, in the last episode, we discussed Social Security disability claims denial.
 
 Speaker A [00:00:55]:
 And I promised you that in this episode we were going to dive into one of my favorite topics, medical records. Now, this is a critical part of any Social Security disability claim. And you might assume that just telling the Social Security administration about your diagnosis is enough, or that your daily pain, fatigue or mental health struggles will speak for themselves. Here's the truth. If those experiences that you have with with your pain and dysfunction aren't backed by detailed, consistent and credible medical documentation, your claim is at serious risk of being denied. Medical records are more than just background. They are the evidence in conjunction with your testimony and vocational testimony. They are what Social Security relies on in deciding whether your condition meets the legal definition of disability, which is the five step sequential evaluation.
 
 Speaker A [00:01:52]:
 And even without these medical records, you have a long shot of getting benefits. Without the right medical records, even the most legitimate claim is going to fall apart and your claim is going to be denied. So I want to walk you through exactly why these records matter so much, what Social Security is really looking for is, and how gaps or vague notes can sink your case. I'm going to explain to you how to gather the right documentation from the right providers and how to get it into the hands of the people reviewing your file. You should also understand this new, relatively new electronic record system and how it works, where it falls short, and what you still need to do to be proactive. So if you are in the middle of the Social Security claims process or you're just starting, this episode is a must. Listen. Because when it comes to getting approved, your story matters, but only if it's written in your medical records.
 
 Speaker A [00:02:56]:
 Got it. Now, I'm going to talk about three things today. Number one, why medical records matter so much in your Social Security disability claim. Number two, how to gather and submit the right medical evidence. And three, what every Social Security disability Applicant needs to know about the electronic record retrieval system. Got it. Let's take a quick break before we come back.
 
 Speaker B [00:03:18]:
 Are you considering filing for Social Security disability, or has your claim been denied already? Either way, you require a copy of your rights to Social Security disability benefits, which will cover everything you need to know about the Social Security disability claims process. Request your free copy of the book@kvlaw.com today.
 
 Speaker A [00:03:53]:
 Welcome back to Winning Isn't Easy. Why medical records matter so much in your Social Security disability claim. Now, I will tell you that when it comes to winning a Social Security disability claim, there's one type of evidence that outweighs everything, and that's your medical records. I want you to think of them as the foundation of your entire case. We want to build a winning pyramid. Okay, so we're talking about the base of the pyramid is not just background information. This is legal proof that Social Security relies on to determine whether your medical condition qualifies as a disability under the rules. Your testimony matters.
 
 Speaker A [00:04:28]:
 I get that. Your daily struggles matter. I get that. But if it's not backed up by documented medical evidence from licensed providers, Social Security isn't going to give your claim the weight it deserves. Now, let's talk about what's important here. One of the first things that Social Security has to determine is whether or not you have a medically determinable impairment and guess where that determination comes from. Your medical records. So the medical records are going to speak to, and should speak to, a detailed timeline of your health, your diagnosis, your symptoms, the progression of your symptoms, the treatment you're getting, your response to the treatment, medications, your response to medications, objective testing results such as X rays, MRI, CT scans, lab results, even referral to specialists.
 
 Speaker A [00:05:21]:
 Now, I will tell you, while they should offer insight into how your condition limits your ability to perform basic work activities, I rarely find that to be the case. And certainly in VA records, which are practically worthless in my opinion. What ultimately needs to be addressed are practical things like sitting, standing, walking, bending, stooping, whether you have any exertional impairments, whether you have problems with bilateral manual dexterity, whether you have any postural issues, whether you have problems with staying on task, meeting pace of production requirements, whether you would be absent from work. These things are all really crucial because Social Security is going to first start out with the question of, number one, do you have a medically determinable impairment? If the answer is no, your claim is going to get denied. If the answer is yes, then they're going to be going through the five step sequential evaluation and the important provisions of the five step sequential evaluation are step three, which is where you potentially the question is, do you meet a listing? At step three, Social Security has a book called the Listing of Impairments based on Body Systems. You can open that book and see if your medical condition is a listed condition. Now, for example, fibromyalgia is not a listed condition at the listing level. Social Security is going to open that listing, look at the elements of the listing, look at your medical records and check things off.
 
 Speaker A [00:06:48]:
 The problem, of course, is the doctors didn't go to medical school to write a report for Social Security purposes, much less to see whether you meet a listing. So I will tell you that 90% of the time, people don't meet a listing. That means that the analysis goes on to step four and step five. At step four, the issue is, can you go back to the lightest job you held in the five years before your claim was decided? And at step five, the issue is, is there other work in the mythical, hypothetical, not real world national economy that you wouldn't want to do that does not pay a living wage in view of your age, your education, your skills, and those restrictions and limitations? And so what I will see is that Social Security will deny claims simply because there isn't enough medical evidence in the file or because what's been submitted doesn't clearly show the severity or duration of the medical condition. So for example, you might have a chronic back problem and your claim might be denied because the only thing in the file is an MRI with no follow up notes from a treating physician explaining the objective physical findings on examination and how the MRI documents the level and severity of your problem and how ultimately that positive MRI and your back complaints and exam findings impact your mobility, cause you to have pain, impact your daily functioning. Now I want you to remember that probably half of the NFL players running around on the field have herniated discs and so they're out there playing football. Simply because you have an objective finding on a diagnostic test doesn't mean you're disabled. Diagnosis does not equal disability.
 
 Speaker A [00:08:31]:
 What you have to do is connect the dots between the diagnostic study, the physical exam findings and your symptoms. Because ultimately Social Security is going to be determining whether or not the level of your severity of your complaints or dysfunction is consistent with what's in those medical records and what's in the diagnostic studies. You also need to understand that if it isn't written down in those medical records, Social Security is going to assume that it doesn't exist. Medical records aren't just helpful. They're essential. They need to be comprehensive and recent. And please don't submit a letter from the doctor that says you can't work. It's not even worth the paper it's written on, much less whatever you had to pay.
 
 Speaker A [00:09:10]:
 Why? Well, because Social Security uses the five step sequential evaluation test to determine whether you're disabled. They couldn't care what your doctor has to say because your doctor doesn't use the five step sequential evaluation test. It's their job, Social Security's job to determine whether you meet the five step test, not your doctor. Your doctor's role is is to document your symptoms, your complaints, your physical exam findings, and ultimately your functional, physical, cognitive or psychiatric restrictions and limitations. Got it. Let's take a break. Welcome back to Winning Isn't Easy how to Gather and Submit the Right Medical Evidence now we've established just how crucial your medical records are, let's talk about how to get them and just how to get them in the right hands. You need to start by compiling a complete list of every medical provider you have seen since your condition began.
 
 Speaker A [00:10:12]:
 That's going to include your primary but also specialists like neurologists, orthopedists, rheumatologists, pain management providers, psychiatrists, any medical professional involved in your case. Don't forget urgent care clinics, hospital ERs, physical therapy notes. Now, even chiropractors or social workers may have relevant notes, though those are not considered to be admissible or accepted medical sources. Their history is important, but their opinions will not be considered by the Social Security Administration or the judge. Now that we've got our list, name of the provider, address, you're going to have to request the records going back at least a year before the date you say your disability began. Now, in some cases, Social Security may want to see records back five to 10 years, especially if you're applying for benefits on a long standing or degenerative condition. In that case, I get those records and I want to submit them. You will have to complete and submit medical release forms known as SSA 1827s to get your medical records released.
 
 Speaker A [00:11:20]:
 Or you can of course, use your own set of your doctor set of medical releases. But once those forms are signed, you or your representatives are going to contact the medical provider's records department. Now some offices will accept fax or email, others will require written or in person requests. But I will tell you that it's something that you got a bird dog. While federal law technically allows them 30 days to respond, delays are common, especially with busy practices or Providers and there are some doctors who still don't use digital records. It's not unusual for it to take 45 to 60 days to receive your records and it can require multiple follow up calls, letters, or even in person visits. Now Social Security will be requesting your medical records and there are some providers who have signed up for electronic access. So it's easy for Social Security to get the records, but I never trust that they get the whole record.
 
 Speaker A [00:12:12]:
 Now you may be tempted to just get on to something like MyChart or your medical provider's medical records access. That's great, but I find that those records are not complete. You may not get all the diagnostic studies, the lab work, all of the relevant information. So I would not necessarily be using that type of service. I would actually be writing a letter or an email with follow up to get your entire chart. If you're getting psychological records, I will tell you the provider won't send them to you. It's just not going to happen. You may ask them to send your records directly to ssa.
 
 Speaker A [00:12:47]:
 Once you've received the records, you need to make sure they're submitted to SSA correctly at the initial and recon stages. That means uploading them through the SSA's online portal or mailing them to your local field office. I've had cases where people have actually hand delivered them and gotten receipts and still the records didn't make it into the file. You kind of wonder exactly what's going on. Now, if your case has reached the hearing level, your representative can upload them directly into the electronic case file. The timing matters. Social Security wants to review the records before making a decision. So the sooner you get them and submit them, the better.
 
 Speaker A [00:13:25]:
 And here's a final tip. Don't assume that Social Security will request everything for you. They do send out records requests early in the process, but they often don't follow up. And if your provider doesn't respond, your file might be considered complete, even if crucial records are missing. That's why it's interesting when I talking to clients about the initial denial at IA and they list the records that they allegedly got and we know that they didn't get all of the records or they didn't get the complete chart. So don't believe that the records are complete. It's up to you or your representative or attorney to make sure that all of the medical records are obtained and timely submitted to Social Security. I'm going to talk about in our next segment, Social Security's digital retrieval system.
 
 Speaker A [00:14:13]:
 In the meantime, let's take a quick break.
 
 Speaker B [00:14:16]:
 Struggling with your Social Security disability case? The right attorney can make all the difference. Get our booklet the key to hiring a Great attorney for your Social Security disability case. Discover how to find an experienced attorney who will fight for your rights and navigate the process with ease. Don't leave your future to chance. Request your free copy@kvlaw.com today and ensure you have the expert support you deserve.
 
 Speaker A [00:14:57]:
 Welcome back to Winning isn't easy, but every Social Security disability applicant needs to know about the Social Security Administration's electronic record retrieval system. Medical records are the key to getting your benefits. You have to establish that you have a medically determinable impairment. You also have to establish at step three that you potentially meet a listing, or at step four and five that you can't, because of your disabling conditions, perform your past work that you've done in the five years before your case is decided, or do other work in the mythical hypothetical, not real world national economy. In view of your age, education, skills and restrictions and limitations, your medical records are the key to meeting your burden of proof. Now, Social Security has developed something called an electronic record retrieval system. It's known as hit. It's an electronic records transmission program that lets Social Security ask for and get your medical records from participating medical providers, allegedly instantaneously and at no cost to you or your representative.
 
 Speaker A [00:16:01]:
 Right now, only agency staff can use the HIT directly. We are hearing that some offices of hearings are doing records requests. I think that's a bit of a hit or a miss in my experience. Now it's not available for me to use and as a result we still request records from each provider. And of course, if the provider isn't enrolled in the HIT program, you've got to get them anyway. Many small medical providers don't participate, so we do a written request and even some large medical providers don't participate. So we are making written requests and we have a staff member whose job it is is to do nothing but to request medical records and to follow up and to bird dog them because we need those records. Now I want you to understand again that those records are key.
 
 Speaker A [00:16:51]:
 You might be tempted to try to get the records from your own medical portal. And as I've said, that's great, but we're still going to request those records because in our experience those records aren't complete. Now people often ask, well, doesn't that cost a lot of money? And in our practice we advance the cost of getting those medical records. We can't win a case without Those medical records. And we want the whole chart. If we have to pay 25 cents a page, ha ha, $1 a page or a flat fee, we're generally going to be doing that. If we are trying to get a medical record, a chart from a hospital, we ask for selected portions of the medical record. We don't want all the nursing notes, that sort of stuff.
 
 Speaker A [00:17:39]:
 So we want an abbreviated chart that contains things like the admit, the discharge, surgical reports, reports of specialists, that sorts of things. So we try to keep that expense as low as possible, but again, we can't. You can't win without having those medical records. And, and you can't win without continuing to get medical treatment. I know that you might be having financial difficulties, but getting medical treatment is crucial to your recovery, but also crucial to your Social Security claim. Just because the doctor is prescribing the same medication or tells you there isn't a lot that they can do for you doesn't mean that you should stop getting medical treatment. If you do, Social Security is going to presume that you have recovered. So if you getting continued medical treatment, keeping your representative updated as to who you're getting those records is really crucial.
 
 Speaker A [00:18:31]:
 Remember, if we're at the hearing stage, we need to file all of the medical records and documentation at least five days prior to the hearing. So if you tell your lawyer in a prep call about some new doctors that you've just seen, or you fail to tell their staff that you're seeing some new doctors and, and it comes out during the course of the hearing, one, the judge isn't going to be happy, and two, the judge most likely will not let those records come into evidence because they weren't timely filed. Got it. Medical records are key, and you need to keep your attorney representative advised. And as part of those medical records, we want to make sure that you are getting applicable residual functional capacity forms. Doctors won't necessarily tell you about these. Social Security will never tell you about these, but these are forms that we lawyers have created that address, I think, over 80 different medical conditions. We want the doctor to address the elements of the listing.
 
 Speaker A [00:19:29]:
 We want the doctor to document your functional, physical, psychiatric, and cognitive restrictions and limitations. Because remember, you have the burden to prove that you meet a listing at step three, at which point benefits are automatically awarded. Or you have the burden to prove essentially at step four and essentially at step five, that you can't do your past work or other work in the national economy in view of your age, education, skills, and restrictions. I know they're supposed to be burden shifting at step five, but that really isn't the reality. You really have the burden of proof and your medical records. The story that those medical records tell about your symptoms and functionality, that residual functional capacity form in combination with preparation is really key to getting your Social Security disability benefits. Got it. Well, that's it for today's episode of Winning Isn't Easy.
 
 Speaker A [00:20:23]:
 I hope that today's discussion gave you a clear picture of how critical your medical records are when it comes to winning your case. It's not enough to have a diagnosis or to say that you're struggling or you're in pain, or your friend down the street who has a worse medical condition, who doesn't have a medical condition as severe as yours is getting the benefits. Who cares? What matters is what's documented. Your symptoms, your functionality, the objective basis of the diagnosis, the fact that the documents and your testing correlate with the level of the severity of your symptoms. All are key. From dates and details to providers and follow up notes to your medical records are the foundation of your claim. And without them, Social Security simply isn't going to see the full picture of how your condition limits your ability to work. Now, I know we covered a lot today, but I think it's really crucial that you understand the role of medical records and why medical records carry so much weight.
 
 Speaker A [00:21:23]:
 If you're applying for Social Security or a claim has been denied, Knowing how to manage your medical evidence isn't optional. It is essential. And in doing so, you should be represented, certainly at the hearing stage, by a Social Security attorney or representative, because they will work with you to make sure that Social Security has all the relevant medical records that you're getting functional capacity forms, and that you understand what's in your medical records and what it is you have to prove in your particular case to get the benefits you deserve. If if you found this episode helpful, please take a moment to like our page, leave a review and share it with your family or friends. And of course, subscribe to this podcast. Thanks for listening.