Core Medical Records for SSDI in Virginia

The SSA looks for records that prove both your diagnosis and your functional limitations. These typically include:

• Doctor’s treatment notes – Records from your primary care doctor and specialists
• Hospital records – ER visits, hospitalizations, and surgeries
• Diagnostic test results – MRIs, X-rays, blood tests, EKGs, CT scans, and lab reports
• Medication history – Prescriptions, dosages, and side effects
• Therapy records – Notes from physical therapy, occupational therapy, or mental health counseling

Specialist Reports

SSA places strong weight on records from specialists in your condition, such as:

• Neurologists for epilepsy or multiple sclerosis
• Orthopedic surgeons for joint and spine disorders
• Psychiatrists and psychologists for mental health claims
• Cardiologists for heart-related conditions

Functional Limitations Documentation

Medical evidence should also show how your condition limits your ability to work, including:

• Restrictions on lifting, walking, or sitting
• Cognitive or memory impairments
• Pain levels and how they affect daily activities
• Work capacity assessments from your doctors

SSA-Ordered Consultative Exams (CEs)

If your medical records are incomplete, the SSA may schedule a consultative exam with a doctor they hire. While this exam is short, it can influence your case—so providing strong medical records upfront is always better.