WHAT IS NOT IN YOUR MEDICAL RECORD? A MOST IMPORTANT QUESTION!

Most individuals going before Social Security to try for disability benefits don't know what's in their medical record.  Even fewer people know what is not in their medical record.

Medical records are what Social Security will base their decision on.  Other factors will be considered but if the medical evidence doesn't support the claim, it will be denied.

Here are some essential things not found in the record of denied claims:

1)  A Residual Functional Capacity (RFC) determination from the claimant's treating physician.  The RFC estimates the claimant's functional limitations:  how long he/she can sit, stgand, walk; maximum weight that can be lifted, how often the claimant can work without taking a break, etc.  Social Security never obtains this from doctors.  They will make up an RFC to suit themselves and it is almost never favorable to the claimant, resulting in a denied claim.  Be sure that your doctor provides an RFC.

2)  A Medical Source Statement (MSS) from a treating physician.  The MSS is like a Residual Functional Capacity form but may not be as detailed.  This written statement outlines why the claimant is unable to work an 8-hour day, 5 days per week on a "regular and continuous basis."  Caution:  A doctor's statement which simply says, "In my opinion this patient is totally disabled and cannot work," is not worth the paper it is written on.  It does not explain why the patient can't work; it fails to give the limitations that would prevent all work.  For example, the MSS might add:  This patient cannot sit for more than 4 hours per day and would be limited to standing/walking no more than 2 hour per day."  Or, "The patient will need to take a break once an hour because of chest pain and shortness of breath."

3)  An explanation of why the claimant stopped working.  Ideally, we'd like to have a written statement by the former employer or supervisor that outlines the claimant's difficulty in performing his or her past work.  An effective letter would say something like this, for example:  "I observed that Mr. _____ would have difficulty bending and reaching overhead.  He seemed to tire easily and often required extra breaks during the day.  He often complained of pain to a point that he had to leave work early and he called in too sick to report to work at least 3 times per month."

EXPLANATION:  When asking your doctor to provide a Residual Functional Capacity (RFC) or Medical Source Statement (MSS), be sure to explain that you don't need a special examination or evaluation.  These forms simply ask for the doctor's opinion of your functional abilities based on the doctor's experience and observations.  Some doctors misunderstand and want to refer the claimant to a rehabilitation doctor for a special exam, which is not what the RFC/MSS is all about.

This is a lot for a disabled claimant to try to coordinate.  If he or she has an attorney/representative, they will handle this.  A primary job of the representative is to be sure all medical evidence is obtained and this includes a valid RFC/MSS, if possible.
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THE FORSYTHE FIRM
7027 Old Madison Pike, Suite 108
Huntsville, AL 35806
SOCIAL SECURITY JUSTICE STARTS HERE 

CALL US:  (256) 799-0297