What Makes Your Health Records Count? Understanding Competent Medical Evidence
When the Department of Veterans Affairs (VA) reviews a veteran’s health history, not all documents carry the same weight. Some records may not qualify as strong medical evidence, or they may carry less weight because they lack clarity, specific details, or professional qualifications.
Understanding the difference between different types of evidence can help you recognize potential gaps in your documentation. This process is about gathering information; it is not a guarantee of any outcome, and it is not a replacement for legal or financial advice.
Defining Competent Medical Evidence
The VA defines competent medical evidence based on two main things: who provided the information and what the information says.
Competent medical evidence is information that is:
- Provided by a person who is qualified by education, training, or experience (like a doctor or a nurse practitioner), and
- Authorized to give medical diagnoses, opinions, and statements
If the document is provided by someone who doesn’t meet these qualifications, the VA may not consider it to be competent medical evidence.
What makes evidence “competent” for VA purposes?
Competent medical evidence must come from a qualified medical professional who is authorized to offer the specific medical diagnoses or opinions, as defined by the VA.
Records That May Not Qualify as Competent Evidence
The types of documentation listed below are often used to support a benefits pursuit, but they typically cannot stand alone as medical opinions. They can still be very useful, but they need to be paired with strong clinical records.
1. Documents Written by Non-Medical Individuals
These documents are often called Competent Lay Evidence. They are valuable because they describe things you or others have observed (what you can see, hear, or experience), but they cannot give a medical diagnosis.
Examples:
- Notes from friends, family members, or spouses (often called “buddy statements”).
- Personal journals or diaries.
- Statements from former supervisors or unit members.
Lay evidence is great for describing observable facts (like how often symptoms occur or how a condition affects your daily life) but must not replace a diagnosis or clinical opinion from a professional.
Can buddy statements count as medical evidence?
No. Buddy statements are lay evidence (non-expert testimony). They are valuable for describing observable facts (like symptoms or service events) but cannot substitute for a medical opinion or diagnosis.
2. Medical Notes Missing a Diagnosis or Clinical Opinion
A health record that only states a symptom (such as “back pain” or “headaches”) without a formal diagnosis, a clinical assessment, or a medical explanation for the symptoms may not offer enough detail to be considered competent evidence.
- Symptom Only: “Veteran reports knee pain.” (Less helpful alone)
- Competent Finding: “Veteran has osteoarthritis confirmed by X-ray, causing pain and restricted range of motion.” (More helpful)
3. Records With No Objective Findings
Objective medical findings are tests or measurements that support the clinician’s conclusion. Records that lack these findings may carry less weight because they lack objective, measurable proof of the severity described.
Examples of Objective Findings:
- Imaging results (X-rays, MRIs, CT scans).
- Lab results and blood tests.
- Physical measurements, such as range-of-motion test results.
4. Records That Lack Dates or Timeline Information
To show a condition is long-term (chronicity), the VA needs information that shows how long a condition has existed and how it has been treated.
Documents may be less helpful if they:
- Lack clear dates of service or treatment.
- Do not show follow-up visits or consistent care over time.
- Have large, unexplained gaps in treatment.
Without a clear timeline, reviewers may have difficulty determining whether a condition is short-term or chronic.
5. Documents From Clinicians Outside Their Expertise
The VA looks closely at the qualifications of the person providing the opinion. A note from a clinician discussing a highly specialized area outside their typical expertise (for example, a general practitioner giving a detailed opinion on a rare heart condition) may be assigned less weight than an opinion from a specialist in that specific field.
6. Automated or Template-Style Notes Without Clinical Detail
Documentation that appears rushed, generic, or non-personalized may contribute less to understanding the veteran’s specific condition.
Examples:
- One-word checkboxes or template-driven scripts without a personalized assessment.
- Notes that copy-and-paste boilerplate language with no individualized rationale.
What Records Do Count as Competent Evidence?
In contrast to the list above, the VA considers the following to be competent medical evidence when provided by a qualified clinician:
- Diagnoses and the reasons behind them.
- Imaging and lab reports (showing objective findings).
- Physical exam findings and measurements (like blood pressure or range of motion).
- Specialist evaluations (e.g., from a Cardiologist or Psychiatrist).
- Medical opinions with clear supporting facts and reasoning.
- Hospital and inpatient records.
How Non-Competent Evidence Can Still Help
Even if a record doesn’t qualify as competent medical evidence, it still holds probative value (weight) when used alongside medical records.
For example, a buddy statement (lay evidence) cannot diagnose a condition, but it can confirm the frequency of observable symptoms (e.g., “I witnessed his social isolation once a week for the last year”).
Adding the Crucial Link: Why Competent Evidence Needs a Nexus
Competent medical evidence is essential, but for the VA to grant benefits, the evidence usually needs to show a connection, or nexus, between your current medical condition and your military service.
The VA may need a medical opinion that clearly states:
- Current Condition: You have a specific, diagnosed condition (the competent evidence part).
- Service Connection: It is at least as likely as not (a 50/50 chance or higher) that this condition was caused by, was aggravated by, or is otherwise related to an event or injury that happened while you were in service.
This type of clear medical link is often provided by a qualified health professional through a specific medical opinion. Without this medical opinion clearly establishing the connection, even competent evidence of a diagnosis may not be enough for the VA to grant service connection.
How Trajector Medical Can Assist Your Benefits Pursuit
As medical evidence experts, we can assist veterans by focusing on the evidence needed for a benefits pursuit, while always keeping the process client-driven. We do this by:
- Helping you gather all your existing medical and non-medical records.
- Reviewing your documentation to help you identify areas where medical clarity or detail may be missing. It’s up to you to decide what to do next.
- Organizing your records so that patterns, timelines, and the history of your condition are easier to understand for reviewers.
We’ve helped tens of thousands of people like you to get the most accurate disability rating their conditions warrant. Learn more about our services and begin your FREE Medical Evidence Consultation today.
