In a recent post entitled Treatment Records, New York disability attorney Jeffrey Delott stated:
Treatment notes basically serve as a way to remind the physician of things she or he may need to remember at a follow up visit. Many relevant physical exam findings are not included either because, for example, they may have been previously reported and would be redundant, are obvious such as walking with a cane, or are implied, such as trigger points for fibromyalgia. Claims adjudicators frequently try to deny a claim by relying on treatment notes’ omissions as evidence that a person lacks “objective evidence” to support a claim. Therefore, it needs to be pointed out that treatment notes do not serve the same purpose as a narrative or other disability report, which is why they may appear different.
Mr. Delott is right. A doctor’s progress notes are maintained to keep track of the patient’s medical care. They are not created for the purpose of establishing disability. That is why a doctor’s progress notes alone are often not sufficient in a Social Security disability claim. An opinion from the doctor is often required. And the doctor’s opinion may assess limitations that are not noted in the patient’s treatment records. That is not unusual, because the treatment records have a different purpose than a doctor’s opinion letter or medical source statement.
Be sure to tell your doctor about your functional limitations, and hopefully those limitations will find their way into the doctor’s progress notes. But you should understand that your medical records alone may be insufficient to establish the functional limitations that Social Security uses to assess your claim.