Introduction
If you’ve ever filed a disability claim, you’ve probably heard the phrase, “Let the evidence speak for itself.” But in the world of veterans’ benefits, it’s not enough to just submit a thick file of medical records and hope for the best.
The VA looks for specific types of evidence—and they often overlook or undervalue others.
So, what exactly is the VA looking for in your medical records? What helps? What doesn’t? And how can you present your documentation in a way that supports—not stalls—your claim?
This guide breaks it down, so you can turn your stack of paperwork into a clear, credible case.
Why Medical Evidence Matters
Medical records are the foundation of every disability claim. They prove three key things:
You have a current diagnosis
The condition occurred or was aggravated during service
There’s a nexus (link) between your condition and your service
Without strong medical records, the VA has little reason to approve your claim—no matter how real your symptoms are.
What the VA Looks for in Medical Records
✅ 1. Documented Diagnoses
This is the starting point. If you claim a condition—like sleep apnea, migraines, or PTSD—but there’s no formal diagnosis in your records, the VA is likely to deny the claim.
They want to see:
Diagnostic codes
Notes from specialists
Results from labs, imaging, or sleep studies
Tip: If you were diagnosed by a private provider, include those records. VA facilities don’t always share info with outside doctors.
✅ 2. Symptoms Documented Over Time
The VA gives weight to records that show consistency. A one-time note saying “back pain” isn’t as powerful as multiple entries over the years documenting:
Severity
Treatment (e.g., physical therapy, prescriptions)
Activity limitations
Flare-ups
These repeated mentions create a timeline that shows your condition isn’t occasional—it’s ongoing.
✅ 3. In-Service Medical Events or Complaints
If you were treated or evaluated for a condition during your time in the military, make sure those records are included. The VA pays attention to:
Injury reports
Sick call notes
Deployment health assessments
Separation physicals
Tip: Even a complaint with no formal diagnosis can help if it ties your current issue to your time in uniform.
✅ 4. Statements Linking Service to the Condition
If your provider mentions your military service in the context of your diagnosis, that’s valuable.
For example:
“Veteran reports back pain beginning after a fall during field training in 2009.”
Even better if the doctor includes a note like:
“Symptoms are consistent with injury history and physical stress experienced during military service.”
These connections—even brief ones—can make or break the “nexus” piece of your claim.
✅ 5. Documentation of Secondary Conditions
The VA often approves claims for conditions caused or worsened by other service-connected issues. If you have a rated condition (like a knee injury) and develop something secondary (like hip pain or depression), make sure your records:
Reference the original condition
Show how the new condition developed
Include treatment notes showing progression
What the VA Often Ignores or Undervalues
Now for the frustrating part: some information just doesn’t carry the weight you think it should.
❌ Personal Research or Internet Articles
No matter how good the source, the VA won’t base your claim on WebMD printouts or medical journals you find online. These can support a doctor’s opinion—but they can’t stand alone.
❌ Vague Medical Notes
Doctors often write notes like “chronic pain” or “patient reports headaches,” but without context or severity, these can be too weak to support a claim.
Translation: If your records don’t say how a condition limits your life or ability to work, the VA may call it “non-compensable.”
❌ Records Without a Diagnosis
If you complained about a symptom but never got a clear diagnosis, the VA may ignore it—unless you link it to a current, diagnosed condition through a nexus letter or updated exam.
❌ Notes That Don’t Mention Service
Even if you have excellent civilian treatment records, if they never mention your military background, the VA won’t automatically connect the dots. That’s why supporting statements (from you or your provider) are so important.
How to Strengthen Your Record Before You File
Want to make your medical records speak more clearly to the VA? Try these strategies:
✅ Get a Copy of Your Service Treatment Records
Request your full military medical file from the National Archives or VA.gov before filing. These can reveal forgotten notes from sick call visits or old injury reports.
✅ Talk to Your Doctor About Your Claim
Explain that you’re filing a claim and need clarity in your documentation. Ask if they can:
Summarize your diagnosis clearly in your records
Link it to military exposure or injury (if appropriate)
Write a nexus statement if willing
✅ Include a Personal Statement
Even if your doctor didn’t write something down, you can. Include a VA Form 21-4138 (Statement in Support of Claim) explaining:
When your symptoms began
How they’ve changed over time
Any impact on your work, sleep, or relationships
Lay evidence like this is especially helpful when service records are sparse.
What to Do If the VA Overlooks Evidence
If your decision letter doesn’t mention a key piece of medical evidence, don’t panic—but don’t let it slide either.
You can:
File a Supplemental Claim with the evidence highlighted
Request a Higher-Level Review
Get support from a Veteran Service Officer (VSO) who can flag missed documentation
Final Thoughts
Your medical records are more than just a history—they’re your strongest voice in a system that makes decisions based on paperwork. By understanding what the VA values (and what it doesn’t), you can craft a claim that’s clear, consistent, and compelling.
If your records are messy, incomplete, or unclear, that’s not the end. Take the time to fill the gaps, connect the dots, and give the VA what they need to see: that your condition is real, ongoing, and service-related.
You’ve already done the hard part by serving. Now let your records back up what you’ve lived through—because the evidence should work for you, not against you.
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