Disability Doc

6.00 Checklist for medical evidence

The longitudinal medial record history should cover a period of at least 3 months of observations and treatment, though SSA notes it may be able to make a fully favorable decision without it. For example, SSA would not necessarily need a 3 month history of records if an individual is receiving dialysis for irreversible kidney disease.

Medical record should describe

• How you were treated
• How you responded to treatment
• Any hospitalizations
• Lab tests showing progressive renal disease, such as elevated serum creatinine
• Documented labs on more than one occasion over a 3 month period

Encourage treating sources to submit at least three months of medical records containing lab tests. A general goal is to have treating sources send in 12 months of medical records.

If you are undergoing dialysis, SSA wants lab tests showing your renal function before you started dialysis. This will be found in the medical records of your treating doctor.

Checklist for nephrotic syndrome

• Medical records should describe the amount of anasarca (edema/swelling), including pretibial (shins), periorbital (around the eye), or presacral (lowest part of back) edema.
• A description of any ascites (fluid in the abdomen), pleural effusion (fluid around the lungs), or pericardial effusion (fluid around the heart)
• Serum albumin levels
• Proteinuria (protein level in the urine)

Checklist for renal biopsy

• If performed, evidence should include a copy of the report of the microscopic examination of the kidney tissue (pathology report).
• If the pathology report of the biopsy is not available, SSA will accept a statement from an acceptable medical source that a biopsy was performed, with a description of the results.

6.00 Checklist for treatment

• Medical records should describe the type of therapy
• Response to therapy
• (Short-lasting) side effects of therapy
• Effects of post-therapeutic residuals (long-lasting side effects)
• Expected duration of treatment