As the treating physician, your opinion is vital to the outcome of your patient’s Social Security disability claim. In fact, it may control the outcome of the claim.
Under a recent policy ruling, if a treating physician’s medical opinion is well-supported and not inconsistent with other substantial evidence in the record, it is given “controlling weight.” That is, the judge must follow it.
Your medical opinion, as expressed in your notes, must address the nature and severity of your patient’s impairments. To be “well-supported,” your opinion must be based on medically accepted clinical and laboratory diagnostic techniques. These objective findings are especially important if your patient’s disability is not “obvious” (like an amputation), and the patient’s credibility as to the extent of his/her limitations may be a factor.
“But how can I be sure my opinion is not inconsistent with other evidence?” you may ask. First, be sure your opinions are internally consistent. If your opinion has changed during the history of your treatment, be sure the change is well explained.
Second, find out everything your patient is doing. Your opinion will not be followed if your patient’s actual activities exceed the limitations you have set.
Of course, other medical opinions may contradict or conflict with yours. But even if these are present, your opinion as the treating physician will be given deference as long as it is well-supported.
What if your patient’s disability cannot he based totally on objective medical findings, but is based on symptoms and pain? Your written observations are still important!
First, your records must show there is a medically determinable impairment that could produce the symptoms. Second, the judge must make a credibility finding concerning your patient. Your notes can help, since the judge must consider the entire case record in making this finding.
The judge must consider the patient’s daily activities; the location, duration and frequency of symptoms; and what precipitates and aggravates the symptoms. The amount of medication and their side effects, and what treatment is needed to alleviate symptoms must also be considered. Your statements, as treating physician, will also be considered.
How consistent your patient’s statements are will be assessed, partially by comparing them to statements your patient made to you, which appear in the medical records.
Since symptoms vary in intensity, persistence and functional effect, and may vary with time, inconsistency will not always defeat credibility. But the judge will look to the record for explanations for these variations. So, certain medical evidence may lend credibility to claims of symptoms and pain.
Also, you may record observations which are relevant beyond complaints of symptoms and pain. For example, your patient may express genuine frustration at not being able to return to work. Or during your extensive treatment, you may have observed your patient to be a hard worker. This information will help a judge realize that the disability claim is not for the purpose of avoiding work.
Please note that Federal Regulations now restrict certain doctors, such as those at the V.A. Domiciliary, from writing narrative reports. This underscores the importance of clear and thorough chart notes, since they may be all the judge has to go on.
This article was prepared by Robert F. Webber