Your medical records – the doctor’s treatment notes and progress notes – are created to keep track of your medical care, as a tool to assist your doctor with your treatment. Those notes are not created to be used for the purpose of establishing a disability claim. However, your medical records are the principal evidence for your Social Security disability claim, and they will be used by the Social Security Administration to assess your work-related limitations.
In general, doctors do not focus on your functional limitations. So it is important to tell your doctor what your limitations are. It will help your doctor better understand your medical condition. It may also help your disability case, since eventually those limitations will end up in the doctor’s progress notes, and those notes will be used by SSA to establish your work-related limitations.
Instead of saying “my back hurts when I stand too long,” say “after 15 minutes of standing my back hurts so much that I have to sit down for 15 minutes.” Give the doctor some specific details to quantify your medical problems. The same is true for mental limitations, such as depression or anxiety. Rather than saying “my depression is a little better (or a little worse) this month,” say “I was so depressed that I could not leave the house for 6 days last month.” Give your doctor some specifics.