Slepian Smith, PLLC

Why it is important to keep comprehensive medical records

There are many challenges in applying for Social Security Disability benefits, including filling out paperwork, attending hearings and meeting deadlines. This is in addition to the fact that applicants are injured and trying to focus on recovery. The unfortunate reality is that the Social Security Administration rejects most initial applications.

It is especially important as applicants go through this process to keep meticulous records of all medical treatment they receive and consultations they attend. This is even more critical if the injury is not commonly acknowledged by the SSA (typical injuries include musculoskeletal problems, heart disease, impairment of hearing, sight or speech, or respiratory illnesses).

Below are tips for effectively documenting evidence that will help your application or appeal.

  • Document every medical appointment with a doctor, nurse, physical therapist, specialist and counselor.
  • Keep a comprehensive list of every treatment and procedure as well as prescriptions.
  • Keep all receipts for medication, services and products to treat the illness or injury.
  • Keep a diary or log about the effectiveness (or ineffectiveness) of the treatments.
  • Detail any physical or psychological issues (such as depression or anxiety) that crop up in relation to the injuries or illness.
  • Get your complete medical file from care providers to complement your own records. This ensures that you have all records on hand when needed.

An attorney can also help

Applicants can represent themselves, but it is often best to have an attorney with experience and knowledge to guide a worker through the process, particularly if there is a hearing. An attorney can also help ensure that all necessary papers are in hand, coordinate with doctors and medical experts on behalf of the client, and prepare the client for the many steps involved.

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