What should a medical report include?
Answer In order for a medical report to furnish the Social Security Administration with sufficient medical evidence, it should include: 1. Medical history (longitudinal history is particularly important with mental impairments); 2. Clinical findings (such as results of physical/mental status examination); 3. Laboratory findings; 4. Diagnosis (statement of the disease or injury based on signs, symptoms and lab findings); 5. Treatment prescribed with response and prognosis; 6. Medical source statement based on the medical source s own medical findings describing what physical and/or mental restrictions are placed on your patient. Medical evidence, including clinical and laboratory findings, should be complete and detailed enough to allow Social Security to make the disability determination. In addition, the report should enable Social Security to determine the nature and limiting effects of the impairment(s), its probable duration, and the claimant s remaining capacity to engage in work
In order for a medical report to furnish the Social Security Administration with sufficient medical evidence, it should include: Medical evidence, including clinical and laboratory findings, should be complete and detailed enough to allow Social Security to make the disability determination. In addition, the report should enable Social Security to determine the nature and limiting effects of the impairment(s), its probable duration, and the claimant’s remaining capacity to engage in work related physical or mental activities.
