Why Detailed Doctor’s Notes Are Essential for Successful SSDI Claims

A Doctor’s Statement for Social SecurityDetailed doctor notes for SSDI application

A critical element of applying for Social Security Disability Insurance (SSDI) is submitting a detailed doctor’s letter. A purposefully crafted medical statement strengthens your claim for disability benefits. The effectiveness of such evidence hinges on its level of detail and thoroughness. It should outline the specific limitations that prevent you from working. Trust in the skilled SSDI attorneys at Keefe Disability Law to guide you through this intricate process. 

Medical Evidence to Support Your SSDI Claim

There are two main facets to your disability benefits application. First, there are the non-medical requirements for SSDI. To qualify for SSDI benefits, you must have earned enough work credits based on wages earned, including self-employment income. You must have paid Social Security taxes. You must also be a U.S. citizen or permanent resident between the ages of 18 and 65. 

Proving your disability makes up the second facet of your application. This involves gathering medical evidence to support your claim. To do this, you must work with your doctors. Before applying for SSDI, discuss your intent with your doctor. To be legally disabled, you must be unable to work for at least 12 months. Your doctor can help prove that this is true. 

Why Specificity Matters

A primary piece of evidence in your SSDI application package is a disability letter from your doctor. This is sometimes called a medical source statement. Boilerplate language won’t do, though. The doctor’s notes you submit must be detailed and specific to your case. A standard form letter won’t carry much weight. It could even reduce the chances the Social Security Administration (SSA) will deny your claim. 

The support of your doctor is crucial to your success, but simply confirming your diagnosis isn’t enough. Two people with the same diagnosis may not be equally disabled. One person may be perfectly able to do their job, while the other may not. The specific limitations of your disability can determine whether the SSA approves or denies your SSDI application. The SSA cannot determine if you qualify for benefits based on a generic doctor’s letter. 

Stating you have “difficulty standing” is insufficient. Stating that you are “unable to stand for more than 10 minutes at a time without severe pain and discomfort” is much more detailed. It provides much stronger evidence to support your claim. 

Come Prepared for Your Doctor’s Appointment

To improve your chances of a successful SSDI application, take the time to prepare for your doctor’s visit. Book a free consultation with Keefe Disability Law, and our skilled team can evaluate your case and advise you through this process. Remember, you should see your doctor before you apply for disability benefits.

Doctors are understandably very busy. The easier you can make their job, the more you’ll be able to accomplish during your time with them. Before seeing your doctor, create a list of your symptoms and limitations. Be as specific as possible, relating it to real-world situations. For example, you may indicate that your arthritis has severely impacted your typing ability. You can also describe environmental factors, like heat and cold. Talk about side effects of medications, like greater fatigue. 

Give your doctor a copy of this list to add to your file. They may not be able to test all your limitations during your appointment, but now they are on record in your medical file. And it can help to guide their physical examination or further testing. When your doctor fills out a form or writes their letter, they can reference your list. Your experience with your disability may not be the same as other patients your doctor has seen. 

Your doctor’s professional assessment carries much weight in the SSA’s decision-making process. 

Doctor’s Details to Include in Your SSDI Application

Consult with your Massachusetts SSDI lawyer to ensure your doctor’s letter is complete and thorough. The written statement to the SSA should confirm your disability and provide objective medical evidence to support this claim. Examples of evidence may include medical imaging, blood tests, and clinical exams. While this letter is not a strict requirement of your application, it can be very persuasive. The letter should cover your condition, symptoms, limitations, treatments, and prognosis. The SSA may request an Adult Disability Report and your doctor’s letter. The report may include how your condition has affected your work history. 

List of Conditions

The doctor’s letter should include a list of relevant medical conditions. You may have just one impairment, or you may have several disabilities. It’s crucial to be honest and detailed with your doctor. This way, they can provide an accurate diagnosis. They can describe the effect your disability has on your ability to perform work.

Not everyone is qualified to provide an official diagnosis. Along with doctors of medicine (M.D.) and doctors of osteopathic medicine (D.O.), other medical sources the SSA accepts include: 

  • Licensed optometrists
  • Licensed audiologist
  • Qualified speech-language pathologists
  • Licensed podiatrists
  • Licensed and certified psychologists
  • Physician assistants (PA)
  • Advanced registered nurse practitioners (ARNP)
  • Advanced practice registered nurses (APRN)

Symptoms and Limitations

A very important part of your doctor’s statement is the discussion of relevant symptoms and limitations. As mentioned, not everyone with the same diagnosis will exhibit the same symptoms or the same severity of symptoms. Not everyone with Parkinson’s disease will qualify for disability benefits, for example. This is why it is so important that your doctor’s notes are as detailed and specific as possible. 

Speak with your doctor about specific ways each disorder limits your ability to function at work. Symptoms and limitations go hand-in-hand. You may have a musculoskeletal condition, for instance. This may cause stiff joints and severe muscle pain. As a result, you are unable to lift and carry loads of more than a few pounds over a short distance. Encourage your doctor to be as detailed as possible in describing your limitations. 

The same applies to mental disorders and conditions. Perhaps you struggle with remembering and following instructions. There are medical tests that can evaluate this limitation. This is why bringing a list of symptoms and limitations when you meet with your doctor is useful. Don’t assume they know what you are experiencing. 

Other examples include difficulty climbing stairs, grasping small objects, maintaining conversation, stooping or crouching, or concentrating on intricate work tasks. 

Treatments and Prognosis

A vital component of SSDI requirements is that your disability prevents you from working for at least 12 months or is expected to end in death. It is important to be realistic and honest with your application. It is equally important to continue following medical treatments throughout this process. This indicates to the SSA that you are doing the best you can to get better. 

The letter from your doctor should outline your treatment history, the effects of these treatments, and side effects. Your doctor should also provide a prognosis, forecasting the likely course of your condition. 

Requesting Detailed Medical Records

Your doctor is primarily interested in your medical care. This often consists of tests, exams, medications, and other treatments. For your SSDI application, though, you also need detailed medical records. These medical records supplement your doctor’s letter to substantiate your claim further. 

As the SSA reviews your case, they may contact doctors and hospitals listed in your application. To improve your chances of approval and speed up the process, you can request your medical documents and records ahead of time. The type of evidence will depend on your impairment and other factors. Examples include lab results, imaging scans, surgery reports, and hospital notes. You’ll need these to prove you are disabled. Speak with the trusted legal team at Keefe Disability Law about what records to request and how to get them. 

Potential Mistakes and How to Avoid Them

Detailed doctor’s notes can provide compelling support for your disability claim. As you embark on this process, it’s crucial to avoid making common mistakes. Examples include:

  • Waiting until after you apply to see your doctor
  • Failing to review the relevant Blue Book listing for your disability with your doctor
  • Submitting an application with inconsistent or conflicting information
  • Exaggerating your symptoms and limitations
  • Not preparing for your mental residual functional capacity (RFC) assessment
  • Including insufficient medical evidence
  • Submitting a generic doctor’s letter that lacks specific detail
  • Forgetting to follow up with your doctor about any forms they need to complete
  • Applying for SSDI without the aid of an experienced disability attorney

Get Help Asking the Right Questions

Navigating the SSDI application process can feel daunting. You may not know where to begin or what you should do. It can be difficult to get answers when you’re not sure what questions to ask in the first place. 

To help you understand which documents you need from your doctor, get in touch with the offices of Keefe Disability Law today. The medical evidence you need to support a PTSD claim can be quite different from other conditions, for instance. By knowing what questions to ask your doctor, you can put together a much more compelling application. 

Patrick Hartwig
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Managing Attorney, Keefe Disability Law