Functional Limitations in Your Medical Record Help Get Social Security Disability

The Social Security Administration (SSA) is interested in the effects a claimant's medical condition has on their ability to work. Disability claims examiners at DDS (Disability Determination Services), along with administrative law judges, look for detailed doctors’ notes on what activities a disability applicant is capable of doing. If a doctor has provided little information in the medical record as to what an applicant is capable, or not capable, of doing (called functional limitations), the DDS medical consultant will conjure up his or her own conclusion in this regard. This can lead to a determination that the applicant should be able to do past work, or some other work, and should not get disability benefits.

Functional Limitations Helpful to Assessing RFC

How can physicians effectively note these all-important functional limitations in their treatment notes? By including the information DDS examiners and administrative law judges need to make an RFC (residual functional capacity) assessment. Claims examiners and judges look for information that substantiates an applicant’s functional limitations. In particular, the following information on a patient’s exertional restrictions is helpful.

How much a claimant can lift, on a frequent and on an occasional basis. This information is incorporated into a patient’s RFC rating.  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." (For more information, see our article on how RFC assessments affect the disability determination.)

How long a claimant can sit or stand. This is taken into consideration because a claimant's residual functional capacity in this area (that is, 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.

How well a patient can reach forward and overhead. If the medical issues involved include degenerative disc disease or arthritis in the upper extremities, for instance, the ability to perform overhead reaching or reaching one's arms to shoulder level might be significantly impaired.

How well a claimant can crouch, stoop, or bend. A patient with a back injury may have limitations on the ability to crouch, stoop, or bend. If that's the case, a claimant could not reasonably be expected to return to or go to a job for which the ability to crouch, stoop, or bend is required, such as a job requiring lifting. 

How well a claimant can grasp objects or perform dexterous finger movements. Arthritis as well as neurological disorders like Parkinson’s Disease can affect the ability to use the hands in an intricate fashion (also called fine motor skills). 

How well a patent can hear and see. If a patient has low vision or hearing, their doctor should include specific restrictions, such as no operating hazardous machinery. And of course many sedentary jobs, such as those requiring use of the telephone or computer, require good hearing and vision.

How RFCs Relate to Disability Determinations

A DDS medical consultant will rate your functional ability by doing an RFC assessment. Next, a vocational expert may be asked to determine what types of jobs you can do, if any. The vocational expert will refer to the federal government’s Dictionary of Occupational Titles (DOT), and the DOT supplement, Selected Characteristics of Occupations Defined in the Dictionary of Occupational Titles (SCO). These books describe the physical and mental requirements of various kinds of work. They classify occupations as sedentary, light, medium, heavy and note whether certain occupations require climbing or balancing; stooping, kneeling, crouching or crawling; reaching, handling, fingering, or feeling; and talking, hearing, or seeing. Your claims examiner (or ALJ, if your claim goes to an appeal hearing) will then use this information to decide whether you qualify for a medical-vocational allowance.

Mental Limitations

There are non-physical factors that may be considered as well. Claimants with psychological and/or psychiatric impairments, such as depression or anxiety, are given a mental residual functional capacity, or MRFC, rating. So if, for instance, you have memory problems and cannot retain new information for long periods, your medical records should indicate this. 

Ask Your Treating Doctor to Detail Your Functional Limitations

Ask your doctor(s) to complete a Residual Functional Capacity (RFC) Form. Ultimately, whether a doctor agrees to take the time to fill out the form is entirely in the hands of the doctor. However, you can attempt to gauge the helpfulness of your doctor's records by doing the following:

• Speak with your doctors and let them know you are filing an application for disability benefits. Impress upon the doctors the value of your functional limitations’ being reflected in the medical records.
• Obtain a copy of your medical records to determine whether the type of information has been recorded by your doctors. (You’ll want to make sure your docs really do support your disability claim before you go through a long and drawn out disability application process.)