Functional Limitations in Your Medical Record Help Get Social Security Disability

Your functional limitations are the most important evidence for Social Security disability.

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The Social Security Administration (SSA) is interested in the effects that a disability claimant's medical condition has on his or her ability to work. Disability claims examiners at DDS (Disability Determination Services), along with administrative law judges at disability hearings, look for detailed doctors’ notes on what activities a disability claimant is and isn't capable of doing. If a doctor has provided little information in the medical record as to what a claimant is not capable of doing (called functional limitations), the DDS medical consultant will assume the applicant doesn't have any limitations. 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 Are Helpful to Assessing Your RFC

DDS medical consultant or claims examiner will rate your functional ability by performing an RFC (residual functional capacity) assessment, which is how much work you are capable of doing. To establish your RFC, claims examiners and judges look for information that details and substantiates a claimant'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 desk 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. This can limit the number of jobs a claimant can do.

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). Almost all sedentary jobs require the use of fine motor movements. If you can't use your hands and fingers, you should get a "less than sedentary RFC" and be found disabled.

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, so low vision or hearing can rule out quite a few jobs.

How RFCs Relate to Disability Determinations

After the DDS medical consultant or claims examiner does your RFC assessment, a vocational analyst (or expert, if you're at a hearing) may be asked to determine what types of jobs you can do, if any (including your prior job), given your RFC.

The vocational analyst or 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 also 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 compare the requirements of your past job and various other jobs to the abilities and functional limitations in your RFC. He or she will use this information to decide if your functional limitations prevent you from doing your past work and if your functional limitations prevent you from doing other work.

Learn more in general about how your RFC can qualify you for a medical-vocational allowance

Mental Limitations

Social Security has to consider non-physical factors 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. For more information, see our article on the mental RFC.

Ask Your Treating Doctor to Detail Your Functional Limitations

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 properly assess your residual functional capacity.

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 this 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.)

A disability lawyer can work directly with your treating doctor to document your functional limitations properly. For more information, see our article on how disability attorneys document your limitations.