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Why Medical Report Details Matter in SSDI Claims

By Kenton Koszdin Law Office on July 28, 2014 | In Social Security Disability

When it comes to Social Security Disability Insurance (SSDI) claims, physicians who are doing diagnosis of medical conditions must be conscientious and thorough about the office notes they take concerning a potential recipient’s condition.

Simply saying that a patient is “disabled” is not enough. A clinician has to be very thorough about documenting clinical signs, functional limitations, symptoms, findings, and medical options to support his or her conclusion.

If a claimant can’t work full-time, a doctor must fully document that opinion. For Social Security to make a disability determination, it needs accurate medical records from approved medical providers. Of all the medical evidence provided by doctors, the details on an applicant’s functional limitations (residual functional capacity) is most important.

Those functional determinates include:

  • How much a claimant can lift on an occasional or frequent basis
  • How long he or she can sit or stand
  • How well a patient can reach overhead or forward
  • How well a patient can hear and see
  • How well a claimant can perform dexterous finger movements or grasp objects
  • How well a claimant can bend, crouch or stoop.

If the Social Security Administration denies your claim and you appeal, a disability claims examiner will send your file to a Disability Determination Services (DDA) medical consultant who will evaluate your medical record, your doctor’s notes, and the results of your clinical tests.

In these cases, it is essential that your physician has taken clear and detailed notes. Sometimes, notes are so sparing and lacking in detail that they provide little or no value to an examiner or an administrative law judge.

If you believe you are eligible for SSDI benefits, the attorneys at the Kenton Koszdin Law Office in Los Angeles can help. We can refer you to physicians who are well versed in how the SSDI system works and who will take thorough and exacting notes concerning your condition. Call us toll-free at (800) 438-7734 — or you can contact us online today.

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