Treatment Records

I received a fully favorable decision today from Administrative Law Judge (“ALJ”) Weiss on another federal court remand involving a police officer. The claimant’s doctors concluded that the he lacked the ability to perform sedentary work. The ALJ had Gerald Greenberg testify as a medical expert ("ME"), and he concluded the claimant could do sedentary work.

The cross exam of the ME, who testified the treating doctors’ opinions were inconsistent with their treatment notes, was critical. I was able to get the ME to admit that the treating doctors’ opinions were based on diagnostic testing, and that there were objective clinical signs that supported the diagnoses. More importantly, I got the ME to admit that the purpose of treatment notes is not to provide evidence for a disability matter, which would explain differences between the notes and disability reports. ALJ Weiss accepted the opinions of the treating doctors over ME Greenberg because the former were “consistent with the diagnostic tests, clinical signs and the record as a whole.”

This matter reflects a critical issue when dealing with disability claims. 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.