Can medical record review benefit a PTSD claim?v

Medical record review and analysis is highly beneficial in establishing not only the physical injuries or disabilities alone, but also in substantiating PTSD claims. Want to know how it can be done? A well-built medical record review can analyze the medical records for evidence of PTSD symptoms in the plaintiff, before or after a particular incident that led to the PTSD claim suit.

Before delving deep into the benefits of reviewing medical records, let’s know some basic things about PTSD claims and the root causes.

What is a PTSD claim?

A PTSD or Post Traumatic Stress Disorder claim arises when an individual has witnessed or lived through a traumatic incident in the past and continues to suffer an emotional trauma as an aftermath in the present.

The PTSD symptoms can worsen as to affect the victim’s day-to-day activities and cause behavioral changes in him or her. The victim’s PTSD symptoms not only affects the victim but also his family and friends. When an individual experiences such extensive damages in his activities, relationships or social harmony, he or she can claim for the damages.

An emotional trauma can be experienced by an individual after incidents like:

  • Horrific war situations
  • Huge fires or riots
  • Natural disasters
  • Sexual assaults
  • Terrorist attacks
  • Domestic violence or abuses
  • Violence like murder or brutal attacks
  • Catastrophic accidents

When the people suffer emotional traumas due to such kind of tragic incidents, it can cause anxiety disorders, nightmares or behavioral changes.

The common symptoms of PTSD are listed below.

  • Depression
  • Insomnia
  • Unreasonable anger
  • Experiencing nightmares or flashbacks of the tragic events
  • Memory issues like memory loss
  • Emotional numbness
  • Fear of people or surroundings
  • Seclusion
  • Headaches

PTSD symptoms also can affect physically and may result in physical ailments. Only expert physicians can identify such symptoms and associate them as the aftermath of going through a traumatic experience.

Significance of medical records in PTSD claims

Be it to obtain Veterans Disability benefits or Social Security Disability benefits, the cause and intensity of the emotional trauma should be proved. Medical records for all kinds of psychiatric therapies can be used as a solid evidence to prove your PTSD claim.

Medical records from the past will also be perused to identify the beginning and the progression or worsening of the symptoms. Therefore getting all your symptoms documented in the medical records play a significant part if you want pursue a PTSD claim.

In case of getting a Social Security benefit, make sure you submit all the medical documentation supporting your PTSD and any of your other disabilities, including any documentation of inpatient or outpatient psychiatric care as well as clinical notes from counselling and therapy.

When you submit your disability application, Social Security will often ask for your treatment records from the preceding year. Nevertheless, you should give Social Security access to all pertinent information going back at least a few years.

You should be as specific as you can about your PTSD issues, including a description of how it impacts your day-to-day activities with your physician. You should also list the restrictions your emotional distress imposes on you, such as the inability to socialize with strangers or to be around loud noises without experiencing panic episodes.

A recent episode of PTSD should be mentioned, along with the frequency and length of your response. A doctor’s diagnosis, account of your symptoms, and expert assessment of your mental state should all be included in your medical records.

In Veteran’s disability claims, along with the military records, the veteran’s military medical records and psychiatric treatment records need to be submitted.

Getting a “medical-vocational allowance” will help you to prove that your PTSD disability prevents you from continuing your past work. The work restrictions recommended by the physicians with the reason will support your claim.

You can also get a “Residual Functional Capacity” form signed by a physician to substantiate your inability to continue work due to your psychological impairments.

Why do we need medical record review for PTSD claims?

In the case of a personal injury claim, a meticulous medical record review can pin point if the plaintiff has any pre-existing PTSD symptoms or the symptoms only started after the subject incident. It can point out when, where, and what treatment the plaintiff received, as well as the diagnosis, and the length of the treatment period.

Typically, the medical records examined in PTSD claims are

  • Records from the emergency room
  • Chart notes on admission
  • Notes from nurses/triage notes
  • Reports on pathology
  • Consultants’ records
  • Reports on psychological or psychiatric therapy
  • Discharge summary notes

Any hint of PTSD symptoms like anxiety, bipolar disorder, and depression documented by the nurses or physicians from the ER to the final or current treatment provider will be analyzed thoroughly. The details of the beginning of such symptoms, the progression or worsening of the symptoms, treatment courses, therapies and counseling sessions will be lined up to prove the PTSD claim.

Even if the PTSD symptoms were pre-existing ones, if the subject incident exacerbated the pre-existing condition can be identified from the medical records. From the symptoms documented by different providers, the plaintiff’s severity of symptoms and the treatment progress can be assessed.

A well-experienced medical record reviewer can easily identify if the subject incident was the direct cause of the PTSD symptom or it kindled the already existing one. If so, how far, the subject incident has worsened can be substantiated with evidence from medical records.

Even for Social Security or Veteran’s Disability claims all those above-discussed facts would be considered and summarized. Every vital diagnosis, test result, and treatment plan related to the PTSD symptoms will be narrated chronologically.


An attorney can easily prove the PTSD claims with the assistance of an efficient medical record review. Since the medical record review team includes psychiatrists, reviewing the PTSD-related medical records becomes easy. For the attorneys, reviewing such records would be difficult as they may not understand the psychiatric disorders.

Shouldering with an experienced medical record review partner will benefit the attorneys to have a smooth sail when dealing with the PTSD claims.

Clare Louise