The basis of any Social Security disability claim is a claimant’s residual functional capacity. In other words, the extent of their functional ability despite their medically documented impairments. To make a determination about a claimant’s residual functional capacity, Social Security obtains his or her medical records. Then a doctor (one who will never actually meet the claimant) reviews these records and decides what the claimant would be able to do in various work related areas, such as how long they can sit, stand, walk or lift. In the area of mental impairment, limitations are considered such as social functioning, concentration, persistence, pace, and ability to perform activities of daily life.
Although medical records are the most significant element in a disability claim, they often do not contain the type of information needed to prove disability. This may happen for a number of reasons. For example, a patient who has been treated for the same condition for years may not report a full list of the same symptoms on every visit to their doctor. In other cases, a doctor may have handwritten notes that are difficult or impossible to read. Similarly, a doctor may use an electronic records system which automatically fills areas of an exam report, even though they may not accurately reflect the patient’s current condition.
Claimants can address these pitfalls in a number of ways. First, claimants should continually report symptoms to their doctors at each visit. This may include functional issues such as the following: how long a claimant can sit, stand, and walk at one time; whether and why they need to elevate their feet during the day and if so, how often and for how long; whether they experience significant side effects from their medications; whether they must sleep or rest during a typical day; and how frequently they must take bathroom breaks. Regarding mental impairments, several examples of functional issues includes how often they experience panic attacks and how long they last; whether they have trouble being in public; whether they are able to concentrate on simple tasks; whether they have memory impairment; and whether they can handle normal levels of stress.
Secondly, a claimant should be aware of the substance and content of their medical records. They should know, for example, whether their doctors’ records are legible, or whether their electronic records contain accurate information. With electronic medical records, information is often entered at the time of the initial visit and the information may or not be updated after that point. Some examples of when this is an issue are references to smoking when a claimant previously quit, or references to working when the claimant has been unable to work. Such references are misleading and can be relied upon by a decision maker.
A third way to document limitations in a disability claim is through functional capacity forms. This is a form with questions intended to document a treating physician’s opinion of his or her patient’s impairments such as those mentioned above. These forms can be the most critical piece of evidence in a claim, but a claimant must be proactive in obtaining such a form. Whether or not Social Security gives credit to these forms depends on whether they are consistent with the same doctor’s medical records.
When a claimant’s medical records thoroughly document their limitations, odds of a favorable outcome are greatly increased.
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