Why Medical Documentation Matters

The SSA does not approve disability benefits based on your diagnosis alone. Instead, they need proof of:

• The severity of your condition
• How long your condition has lasted or is expected to last
• The functional limitations that prevent you from working
• Whether your condition meets or equals a listing in the SSA’s Blue Book

Without detailed documentation, your claim may be delayed or denied.

Types of Medical Records You Need

Applicants in Indiana should prepare to submit:

• Physician’s notes and treatment history – including details about symptoms, physical exams, and treatment response
• Hospital records – admission summaries, discharge notes, and ER visits
• Test results – X-rays, MRIs, CT scans, blood tests, and other diagnostic exams
• Surgical records – including procedure notes and recovery status
• Prescriptions – current medications, dosage, and side effects
• Therapy notes – physical, occupational, or mental health treatment progress reports

Statements from Healthcare Providers

In addition to formal medical records, personal statements from your doctors can be powerful evidence. These should explain:

• Your diagnosis and prognosis
• How your condition affects your ability to perform daily tasks
• Specific work-related limitations, such as inability to lift, stand, walk, or focus
• Whether your condition is expected to improve with treatment

Non-Medical Evidence

The SSA may also consider non-medical evidence to support your application, such as:

• Reports from caregivers or family members about your daily limitations
• Work performance records showing a decline due to health issues
• School or vocational training records (if relevant)

Common Mistakes to Avoid

• Submitting incomplete medical records
• Relying only on one doctor’s notes instead of a full medical history
• Failing to include updated treatment records
• Not explaining how your condition limits work-related activities