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Creative Strategies for Tracking Down Medical Evidence: SOAR Team Tips

Tracking down medical evidence can be very challenging, especially if the treating source is unknown. Case managers must develop creative strategies and become good detectives!

Tracking Down Medical Evidence

The qualities of a good clinical detective include curiosity, persistence, and creativity. You constantly need to assess whether the information gathered creates a complete picture of the individual’s life in a way that supports the disability claim. While this process can be challenging, nothing is more rewarding than getting an approval in less than 90 days! Here are some tips and strategies from the SOAR team to help you track down needed medical evidence.

Useful Medical Evidence

Obtain as much information as possible about health care providers an applicant has accessed, including provider name, location, services provided, and the dates of service provision to applicant. 

  • Be aware of the many types of useful evidence for making disability determinations. Keep a "cheat sheet" of where to find useful records.
  • Some of these records are signed by physicians or psychologists and serve as medical evidence. However, information recorded by social workers, nurses, or other professionals is very relevant.
  • Look carefully at progress notes. Sometimes you can tease out functional information and get a better sense of the course of a person’s illness and how they have or have not responded to treatment.
  • Don’t forget collateral information. Friends, family, and associates may have very pertinent and valuable functional information. An outreach worker or other service volunteer may help as well. Be sure to have signed releases to talk with these providers.
Keep in mind, for disability based on a mental illness, DDS requires a mental status exam that was conducted within the past 90 days.
Useful Medical Evidence

Types of Evidence

Where to Look

What to Look For

Psychiatric evaluations & records

  • Community-based behavioral health services
  • Public mental health centers
  • General hospitals
  • Psychiatric hospitals: private & state run
  • Admission summaries
  • Discharge summaries
  • Bio-psychosocial evaluations or reports
  • Progress notes
  • Psychological tests
  • Mental status exams
  • Medication records

Physical health evaluations

  • Clinics
  • Private physicians
  • Hospital reports
  • Specialty health providers (like neurologists or endocrinologists)
  • Diagnostic tests
  • Laboratory results
  • Neurological evaluations

Substance use

  • Substance abuse treatment providers
  • Mental health services for co-occurring disorders
  • Hospital emergency rooms or detox programs
  • Criminal justice: jails, probation, or community corrections
  • Admission summaries
  • Discharge summaries
  • Bio-psychosocial evaluations or reports
  • Progress notes
  • Drug testing
  • Court records and court orders


  • Occupational therapy
  • Vocational evaluations
  • Physical therapy
  • School records
  • Evaluations
  • Reports

Dates of Treatment

It may be difficult for people to recall when they received services.

  • It is helpful to provide a context for people. For example, you might ask, “Was that before you left high school or after?"
  • Work out a timeline from my conversations with applicants and then get the details filled in by carefully reviewing the medical records once they’re received.

Where Was Treatment Received?

It can be difficult for people to identify where they received treatment, especially those who have accessed only acute care and those who have cognitive impairments.

  • Develop a list over time of local places where people frequently receive services.
  • Search the internet for local shelters or service providers that you can call for suggestions of frequently used facilities near where the applicant has lived.
  • Sometimes you just have to send releases to places where you think the person would have received services. This can be useful particularly for local services.
  • Use the Federal Treatment Facility locator on the SAMHSA website.

Keeping It All Organized

Be sure to keep the requests and replies organized.


The SOAR Medical Records Tracking Worksheet can be a very helpful tool!