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Medical Documentation for Disability Benefits

Medical Documentation for Disability Benefits

Tips on Persuasive Disability Reports From Treating Sources

1.)  Consistency. A doctor's report/forms must be consistent as to the medical information they contain and the professional opinions and conclusions that they set forth. Any significant inconsistencies will raise a red flag from either the Social Security Administration (SSA) and/or from a long-term disability insurance carrier (ERISA) as to their credibility and the credibility of your patient's disability claim.

2.)  Credibility. A doctor's disability report/forms must be credible, and they will appear to be credible if they are unbiased, neutral, and professional. As a treating doctor, you must not appear to be advocating for your patient. That will make your report/forms sound biased and unconvincing. You want them to be even-handed, reasonable, and neutral ... the opinion of an expert, not an advocate.

You must be truthful and not given to exaggeration, because over-the-top statements may be perceived as not credible and may undermine a patient's entire disability claim.

3.)  Completeness. A doctor's disability report/forms must be complete and comprehensive. That will make them persuasive. A report should review and briefly summarize the doctor's medical findings and the medical findings from other providers, as well as the results of laboratory, x-ray, imaging, and other objective tests that support your patient's disability.

4.)  Substantiate.  A doctor's disability report/forms must avoid being conclusory. It must state and substantiate a basis for your disability opinion, with objective evidence from the physical examination, laboratory, radiographic, imaging, and other testing data.

What we mean by a “conclusory” statement is a bare-bones opinion that lacks any evidentiary support. For example, a statement such as “my patient is disabled from any gainful employment,” is impermissibly conclusory and unpersuasive, because it lacks a basis for that opinion. In order to be persuasive, a conclusion favoring disability requires a basis for that conclusion, meaning you, as a doctor, must explain why you think your patient is disabled.

For example, a statement of disability would not be conclusory if it read as follows: “My medical opinion is that this patient would be prevented from gainful employment because she has severe (scale 8/10) and persistent (daily all day and every day) back pain from severe lumbar spinal stenosis, as noted on her MRI scan, that does not allow her to sit for 6 hours or more, walk/stand for 2 hours or more, or lift/carry 10 pounds or more."       

5.)  Quantify. A doctor's disability report/forms should use numbers. Describe the intensity of the pain on a 1-10 scale, where “1" is mild and “10" takes you to the emergency room. Indicate the most your patient can lift or carry in pounds (e.g., <10 lbs). How long can your patient walk or stand (e.g., <2 hours)? How often is your patient required to lie down (e.g., every 2 hours or more) and for how long (e.g., 15-20 minutes)? The more specific you are in describing your patient's disability, the more objective and persuasive your report will be.

If you are describing range of motion (ROM), measure your patient's range of motion (e.g., of the shoulder or back) with a goniometer (that measures angles).

6.)  Specificity. In a disability report/forms, review and address your patient's specific job duties, and explain what symptoms prevent your patient from performing those duties.

For example, if your patient has back pain, and has a data/entry job that requires largely sitting, document that your patient is unable to perform that part of her job, because she cannot sit 6 hours or more in a workday, and (if appropriate) has to lie down to rest her back for at least 20 minutes every 1-2 hours because the amount of pain is so significant that it requires her to sit and or lie down. In contrast, the often seen comment:  "my patient cannot work" has absolutely no value whatsoever...zero, zilch, nada (contrary to public opinion).

7.)  ADL's. Your disability report/forms should take into consideration your patient's ADL's (activities of daily living) and what your patient is able or unable to do at home. Can the patient wash the dishes, go shopping, carry-in the groceries, prepare meals, use public transportation, or drive a car? Can the patient take out the trash, cut the lawn, sit and read the newspaper, make the beds, take a bath, or cut their toenails? Can the patient sit and work on the computer..use a hairdryer, walk the dog, or take the kids to school?

These are important “tests” of functional ability, the answers to which may be interpreted by SSA to mean that your patient can perform “equivalent” work in a job.

For instance, if your patient washes dishes at home, a judge may conclude that your patient is not disabled and can work as a dishwasher. If your patient takes care of an elderly grandmother, that may imply to a judge that your patient does her cooking, laundry, and cleaning. If your patient shops for groceries and prepares meals at home, that may imply to the judge that your patient is less disabled than she claims.

An “activities” questionnaire that you administer to your patient may help to identify activities at home that your patient can and cannot do. And, even if your patient is able to do some activities on “good” days, but not on “bad” days, that's important to document in your disability report.                                                                                            

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