The Importance of Medical Records in SSDI Claims 

When a disability or serious medical condition prevents you from working, the impact can be life changing. As you adjust to this new reality, applying for Social Security Disability Insurance (SSDI) may be one of the most important steps you can take to secure financial stability. 

When applying for benefits, gathering the relevant information about yourself for your application can feel overwhelming. The Social Security Administration (SSA) requires documentation of your work history, medical history, and how your disability affects your ability to do basic daily activities.

While every part of your SSDI application is important, the strength of your claim largely depends on your medical evidence. This includes a detailed medical history, your current condition, treatment plans and recommendations from your healthcare providers, and records from doctor visits, evaluations, and other medical appointments.  

In this article, we’ll explain why medical evidence is so critical to SSDI claims, the types of documentation you need to provide—including the growing importance of electronic health records and telehealth documentation—and how to build the strongest possible case to maximize your chances of approval. 

Medical Evidence 

The SSA doesn’t approve claims on the basis of your word alone — they need proof. That proof comes in the form of medical evidence, and it has to show that your condition is documented, verified, and severe enough to impact your ability to work. Without medical evidence, your disability does not exist in the eyes of the SSA. Your case comes down to medical records.

Types of Medical Evidence 

Doctor’s Notes and Reports

Reports and notes from your primary doctor or a doctor that you have been receiving ongoing care from for your condition is one of the most important pieces of medical evidence and the foundation of your claim. This includes:

• Your Diagnosis: The specific medical condition(s) and diagnosis from your doctor. 

• The predicted progression or the future of your condition. 

• Your Limitations: A detailed summary outlining the functional limitations that affect your ability to perform job tasks and other basic functions like sitting, standing, walking, lifting objects, and concentrating. 

Test Results and Lab Work 

The results of certain imaging studies and lab work—as well as copies of those results—ordered by your doctor are important components of your medical evidence. These may include: 

• Blood Tests: Lab tests performed on a blood sample, such as metabolic panels or genetic testing, which can help confirm diagnoses like diabetes or other medical conditions. 

• Imaging Studies: X-rays, MRIs, CT scans, or PET scans that provide visual evidence of abnormalities, injuries, or conditions affecting the body, such as joint damage or internal issues. 

• Other Diagnostic Tests: Cardiovascular tests such as EKGs, neurological tests such as EEGs or nerve conduction studies, and pulmonary function tests (PFTs) used to evaluate respiratory conditions. 

Treatment History 

A record of your treatment including the development of your condition, symptoms, treatment plans, medications you’ve taken (and any side effects), surgeries or procedures and their outcomes, and therapies (physical, occupational, etc.).

Telehealth Records

In recent years since the COVID pandemic, telehealth appointments have become a convenient and widely used option for patients and healthcare providers to connect through video visits. Telehealth appointments are a more accessible way to discuss symptoms, review treatment plans, and receive ongoing care without the need to travel to a doctor’s office or hospital. Many providers also use telehealth to check in on patients, monitor progress, and address concerns that do not require an in-person visit.

Telehealth records can help establish a consistent medical history by documenting regular provider interactions and ongoing treatment for your condition. 

Common Issues and Helpful Tips 

Accessing Electronic Records

• Most doctors’ offices provide patient databases, often through a secure patient portal, where you can view test results, schedule appointments, and sometimes send messages to your healthcare provider. Contact your doctor’s office for specific instructions on how to access your medical records through their system. 
• You can also request visit summaries after your appointments, which document the details of your care and can be sent directly to you.

The Value of Telehealth Records

• Some people may assume that telehealth records are not important; however, that is not the case. Having a telehealth appointment is better than having no appointment at all. Telehealth appointments generally provide the same type of clinical information as in-person visits and give patients the opportunity to discuss symptoms, medication effectiveness, and treatment next steps with their provider. This information is important when submitting medical evidence to the SSA. 
• Telehealth records can serve as critical documentation of consistent, ongoing care and supporting medical evidence in your SSDI application. 

Keeping Copies of Your Medical Records 

The SSA typically requests medical records directly from your healthcare providers during the different stages of a disability claim. However, it can be helpful to keep copies of your medical records on hand in case there are delays in obtaining documentation or important evidence is missing from your file. You should also keep your medical records up to date with any appointments, results, or reports that occur after you submit your application. 

Having this information organized can make it easier to access. Consider the following: 

Chronological Order: Arrange your medical records in chronological order for easy access.  

Types of Documents: Categorize and label documents such as blood test results, imaging studies, physician and specialist reports, treatment notes, and medication histories to help organize your records. 

While the SSA will generally request and obtain your medical records directly from your healthcare providers, it can be helpful to keep a record of your doctors, appointment dates, hospital stays, urgent care visits, notes from appointments, and other medical treatment. Having this information readily available can be useful if the SSA needs additional details about your treatment history or if you need to provide updates about recent medical care. Complete and accurate information can help ensure the SSA has the evidence needed to evaluate your claim. 

Seek Assistance from a Disability Attorney 

Working with an experienced disability attorney can help improve your chances of success.  An attorney who focuses on SSDI claims can guide you through the application process, ensure the SSA has your most up-to-date provider information, and help make sure your claim is as strong as possible heading into each stage of the process. Having representation throughout your claim is beneficial and becomes especially important if your case goes before a judge — which the majority do. At the hearing stage, an attorney works to ensure your medical evidence is collected and complete, thoroughly analyzing your case to put you in the best possible position for a favorable outcome. 

Fierce Advocacy  

Gathering the relevant information about yourself for your application can feel overwhelming. Mistakes happen, and you may not know the rules and requirements to qualify for SSDI benefits. That’s where Nyman Turkish can help. 

Our Firm has a significantly higher approval rate than the national average, is the leading disability firm in the country, and has the best attorneys and supporting staff in the business. We handle every case with care and compassion, all while providing proven results. 

With our no-fee guarantee, you won’t pay any attorney fees unless we secure a favorable outcome in your case, in which our Firm is paid directly by the SSA from a portion of your back pay (25% capped at $9,200).  

There are no upfront costs, and your case review is always free. If you need help with your claim, visit our website or call (877) 529-4773 to connect with a member of our team who will be ready to assist you.