Statutes and regulations make it clear that it is the Social Security administration that decides if a person is disabled, not a medical provider. The role of clinicians is to provide documentation, or evidence on disability. In other words, medical professionals are asked to provide the facts — diagnoses and functional limitations — that are necessary to determine disability. That’s why a simple statement such as “my patient is disabled” is not sufficient.
Social Security regulations place special emphasis on evidence from treating sources because they are likely to be the medical professionals most able to provide a detailed big-picture view of the claimant’s impairments, and may bring a unique perspective to the medical evidence that cannot be obtained from the medical findings alone, or from reports of individual examinations or hospitalizations. TTimely, accurate, and adequate medical reports from treating sources accelerate the processing of the claim because they can greatly reduce or eliminate the need for additional medical evidence to complete the claim.
Many clinicians dread the process of documenting disability, which they consider mysterious, onerous, time-consuming, and hopelessly complex. The era of managed care, with its demands for productivity and efficiency, has amplified their frustration. To facilitate this process, the clinical team should routinely document their patients’ medical impairments in office charts and medical records. And patients should be sure to mention symptoms, and be sure they are written down.