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SOCIAL SECURITY DISABILITY (SSD), SSI

AND

FUNCTIONAL LIMITATIONS NOTATED IN MEDICAL RECORDS

This information may help claimants with representation, as well as claimants who are not represented by an attorney or non attorney representative. Understanding how the Social Security Disability system works can make the difference between winning or not winning the continuing disability benefits and backpay to which a person is entitled. To win a claim for ongoing and past due benefits, claimants should learn about the disability process to improve their chances of winning ssi or ssd - ssdi benefits.

How can physicians effectively note functional limitations in their treatment notes?

Simply by providing the same information that a social security disability claims examiner or an administrative law judge would search for while reviewing a claimant's medical records.

Disability claims adjudicators (DDS examiners and administrative law judges) tend to look for information that substantiates the following:
  1. How much a claimant can lift - social security disability and ssi disability claimants are given an exertional rating. This rating which is performed on a form known as an RFC, or residual functional capacity form, takes into account a number of factors, not least of which is how much weight a claimant can lift on a frequent and occasional basis. For example, the ability to lift ten pounds frequently and twenty-five pounds occasionally equates to a Light RFC, while the ability to lift twenty-five pounds frequently and fifty pounds occasionally equates to a medium RFC.

  2. How long a claimant can sit or stand - this is taken into consideration because a claimant's residual functional capacity in this area (i.e. the ability to sit or stand for certain lengths of time) will have a bearing on the types of jobs they will be considered capable--or incapable--of doing. For example, a claimant with severe knee problems might be considered incapable of doing work that involves prolonged standing. Likewise, a claimant with severe pelvic pain might be considered incapable of doing work that involves prolonged sitting, such as a sedentary job.
Though, these are hardly the only factors that go into determining a disability claimant's capacity rating. Other factors include how well a claimant can crouch, stoop, grasp objects, reach forward and overhead, hear, see...the list goes on.



Additionally, there are non-physical factors that may be considered as well. Claimants with pyschological and/or psychiatric impairments or who are suspected of having a mental impairment (a single mention of "depression" in a doctor's notes can signal this) are given a mental residual functional capacity, or MRFC, rating as well.

The major point to keep in mind is this: the claimant's residual functional capacity rating (physical, mental, or both) will always be based on the information contained in a claimant's medical records.

Therefore, if a doctor has provided little information in their records as to what a claimant is capable, or not capable, of doing, the DDS medical consultant will "conjure" his or her own conclusion in this regard. And this, of course, being a part of the disability determination process, will lead to the following:
  1. A determination of whether or not the claimant should be able to return to their past work.

  2. A determination of whether or not the claimant should be able to perform some type of "other work".

  3. A determination as to whether or not the claimant should be approved or denied for social security disability or ssi disability benefits.

Of course, it goes without saying that even when a claimant's medical treatment sources have supplied strong supporting information (such as detailed records, or perhaps even a detailed letter or an RFC form completed by the claimant's own doctor), a DDS unit physician may still come to an entirely different conclusion (in other words, they sometimes ignore what a claimant's doctor has to say, despite the fact that they themselves have never seen nor treated the claimant).

However, despite this, in most cases an ssd or ssi claim will be strengthened if the records supplied by a claimant's doctors are very clear and unambigous regarding the claimant's functional capacities.

So, in other words, if a claimant is unable to lift more than five pounds or sit for longer than 15 minutes, ideally, the medical records should state this. If a claimant has memory problems and cannot retain new information for long periods, the records should, ideally as well, indicate this.

This, of course, begs the question: What can a person who applies for disability benefits do to ensure that their medical records contain the necessary details?



Ultimately, this is entirely in the hands of one's doctor. However, a disability claimant can attempt to gauge the helpfulness of their doctor's records by doing the following:
  1. By speaking with their doctor, disclosing that an application for disability benefits has been filed, and impressing upon the doctor the value of functional limitations being reflected in the medical records. This, of course, may be easier said than done---but it does allude to the value and usefulness of maintaining a good relationship with one's treatment sources.

  2. By obtaining a copy of one's medical records to determine the type of information that has already been recorded by one's doctors.

Of course, the most effective way for a treatment source to indicate a disability claimant's functional limitations (i.e. residual functional capacties) is via the submission of a letter or a completed RFC form.

Additional information regarding such letters and RFC forms can be found on the following pages:

A letter to support a social security disability case

Make sure your docs really do support your disability claim

What if your doctor won't support your ssd or ssi case?

What is an RFC, or residual functional capacity, form?

Winning Social Security Disability or SSI benefits



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