I represent a 46 year old delivery driver with neck, back, shoulder, and knee problems, who submitted reports from several of his doctors that provided for a very restrictive functional capacity. The administrative law judge (“ALJ”) said that he wanted a supplemental hearing after a consultative examination (“CE”) because he could not understand the basis for the restrictions. I objected to the CE on the grounds that the ALJ was obligated to contact the treating doctors if he believed the restrictions were inconsistent with the medical records.
After receiving additional treatment records, the ALJ cancelled the supplemental hearing and CE. The treatment records did provide a wealth of contemporaneous objective and subjective evidence regarding the claimant’s condition. However, the treatment records did not provide functional limitations, which treatment records rarely if ever do.
The purpose of treatment records is to provide information that the doctor may want to remember at the next exam; not to provide evidence of functional restrictions and limitations for legal proceedings. The Social Security Administration (“SSA”) knows that, which is why it uses forms such as DDD-3883 and HA-1151 to obtain restrictions and limitations from treating doctors. The problem is that ALJs are requiring that treatment records to serve as evidence to support a doctor’s functionality assessment, which is absurd because treatment records serve a completely different purpose.
Physicians do not record all of their observations when taking exam notes, especially ones that have been made before or for which reminding is not needed. If a patient sees a doctor for back pain, the doctor is unlikely to write in that date’s notes that the patient’s back was sore or stiff. However, some ALJs would deny benefits on the grounds that the clinical findings supposedly are inconsistent with the functional restrictions. Asking the treating doctor to harmonize the alleged inconsistency prevents an ALJ from improperly rejecting a treating doctor’s opinion.