Medical record review for attorneys is an important solution for social security disability lawyers because the evidence found in the medical records is crucial for developing the claim or case. When collecting the evidence to support the claim, one needs to be as thorough as possible with the medical record retrieval and review. The SSA (Social Security Administration) reviews every disability the applicant has before making their decision, which makes the medical chart and the presentation of the impairment in it very significant. In most disability cases, attorneys focus on proving why the claimant cannot work at present.

Key Sections of Medical Records

Let us look at the important sections of medical records that need to be reviewed.

• Subjective complaints: This includes documentation on why the claimant had to visit the doctor and the health concerns he/she has.
• Objective inferences: Here, the doctor’s physical examination notes are included.
• Diagnoses for the particular medical condition(s).
• Doctor’s plan of action: Documentation regarding any specialists they are sending the claimant to; new medications prescribed; further testing prescribed.

In the subjective complaint section of the medical records, the SSA will review all details such as what the claimant has said about his/her own symptoms and side effects. Lack of information regarding any of these could lead to claim denial. The medical records should have the evidence to prove that the claimant actually experiences the reported symptoms/side effects. Physical examinations are also very crucial. The SSA would want to know whether the claimant’s doctor physically sees that the claimant has problems with movements, standing, bending, walking and so on. While reviewing the medical records for SSDI attorneys, an experienced medical review team will look for evidence of pain and limitations the claimant is experiencing.

Medical Record Review Key to Develop Medical Evidence

The SSA may require the claimant to attend an independent medical examination to evaluate his/her symptoms and the medical diagnoses. However, the claimant’s own medical records are crucial to prove that he or she received a diagnosis on their own and sought the necessary treatment. The medical records contain clinical findings from qualified medical professionals who treated the claimant. When the different diagnoses are established by a specialist in the field, the medical records are more powerful. Therefore, medical records help the SSA determine whether the claimant’s condition actually prevents him/her from working and finding gainful employment.

A good medical record review team knows that the most valuable records are those pertaining to objective test results. These include MRIs, X-rays, pulmonary function tests and others. These provide clear information that proves the severity of the claimant’s medical condition. In cases such as fibromyalgia, headaches, mental disorders, epilepsy, and immune system disorders among others, the review team will look for records that describe the severity and frequency of the claimant’s symptoms and extract those details. Treatment notes from specialists will help prove that the claimant’s conditions are being consistently treated and that the claimant is complying with the medical providers’ orders. Since a social security disability case relies heavily on the claimant’s medical records, the assistance of an experienced medical review team will help ensure a positive outcome.