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Medical Evidence of Your Disability

Part II: Information

Medical Reports

The Social Security Administration (SSA) frequently asks physicians, psychologists and other health professionals to submit reports about an individual's impairment. It is important for claimants and those submitting the information to know what evidence SSA needs. Medical reports should include:

o medical history

o clinical findings (such as the results of physical or mental status examinations)

o laboratory findings (such as blood pressure, x-rays)

o diagnosis

o treatment prescribed with response and prognosis

o a statement providing an opinion about what the claimant can still do despite his or her impairment(s), based on the medical source's findings on the above factors. This statement should describe, but is not limited to, the individual's ability to perform work-related activities, such as sitting, standing, walking, lifting, carrying, handling objects, hearing, speaking, and traveling. In cases involving mental impairments, it should describe the individual's ability to understand, to carry out and remember instructions, and to respond appropriately to supervision, coworkers, and work pressures in a work setting. For a child, the statement should describe his or her functional limitations in learning, motor functioning, performing self-care activities, communicating, socializing, and completing tasks (and, if a child is a newborn or young infant from birth to age 1, responsiveness to stimuli)

Consultative Examinations

If the evidence provided by the claimant's own medical sources is inadequate to determine if he or she is disabled, additional medical information may be sought by contacting the treating source for additional information or clarification. Another option is to arrange for a Consultative Examination (CE). The treating source is the preferred source for a CE if he or she is qualified, equipped and willing to perform the examination for the authorized fee. Even if only a supplemental test is required, the treating source is ordinarily the preferred source for this service. However, SSA’s rules provide for using an independent source (other than the treating source) for a CE or diagnostic study if:

• the treating source prefers not to perform the examination
• the treating source does not have the equipment to provide the specific data needed
• there are conflicts or inconsistencies in the file that cannot be resolved by going back to the treating source
• the claimant prefers another source and has good reason for doing so; or prior experience indicates that the treating source may not be a productive source.

Consultative Examination Report Content

A complete CE is one which involves all the elements of a standard examination in the applicable medical specialty. A complete consultative examination report should include the following elements:

• the claimant's major or chief complaint(s)
• a detailed description, within the area of specialty of the examination, of the history of the major complaint(s)
• a description and disposition of pertinent "positive" and "negative" detailed findings based on the history, examination and laboratory tests related to the major complaint(s), and any other abnormalities or lack thereof reported or found during examination or laboratory testing
• results of laboratory and other tests (e.g., X-rays) performed according to the requirements stated in the Listing of Impairments
• the diagnosis and prognosis for the claimant's impairment(s)
• a statement about what the claimant can still do despite his or her impairment(s), unless the claim is based on statutory blindness. This statement should describe the opinion of the consultant about the claimant's ability, despite his or her impairment(s), to do work related activities such as sitting, standing, walking, lifting, carrying, handling objects, hearing, speaking and traveling; and, in cases of mental impairment(s), the opinion of the consultant about the individual's ability to understand, to carry out and remember instructions and to respond appropriately to supervision, coworkers and work pressures in a work setting. For a child, the statement should describe the child's functional limitations in learning, motor functioning, performing self-care activities, communicating, socializing and completing tasks (and, if the child is a newborn or young infant from birth to age 1, responsiveness to stimuli)
• the consultant 's consideration, and some explanation or comment on, the claimant's major complaint(s) and any other abnormalities found during the history and examination or reported from the laboratory tests. The history, examination, evaluation of laboratory test results and the conclusions will represent the information provided by the consultant who signs the report

Evidence Relating to Symptoms

In developing evidence of the effects of symptoms, such as pain, shortness of breath or fatigue, on a claimant's ability to function, SSA investigates all avenues presented that relate to the complaints. These include information provided by treating and other sources regarding: the claimant's daily activities; the location, duration, frequency and intensity of the pain or other symptoms; precipitating and aggravating factors; the type, dosage, effectiveness and side effects of any medication; treatments, other than medications, for the relief of pain or other symptoms; any measures the claimant uses or has used to relieve pain or other symptoms; and other factors concerning the claimant's functional limitations due to pain or other symptoms.

In assessing the claimant's pain or other symptoms, full consideration must be given to all of the above-mentioned factors. It is very important that medical sources address these factors in the reports they provide.