Disability Determination - Chart Note Examples
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Disability Determination - Chart Note Examples


Revised December 12, 2011



Example Scenarios

The following tables contain examples of phrases found in chart notes and the corresponding rating:

Bob applies for ABD cash and states knee pain is keeping him from working. Note that radiological findings are not requested or necessary in the scenarios describe below.

Examination findings (chart notes)

Effect on work activities

Rating

Patient complains of transient knee pain, negative for impact on ADLs, negative for redness, swelling, or signs of deformity. ROM WNL.

No effect on basic work-related activities.

none

Patient complains of recurrent knee pain aggravated by running, persistent kneeling, or other prolonged physical activity. Normal gait, ROM WNL. No crepitus or swelling. Recommend PT if symptoms persist.

No significant effect on basic work-related activities.

mild

Patient complains of chronic knee pain aggravated by climbing stairs, kneeling, walking. Has decreased physical activity over the last few months with no relief. Limp observed, knee appears swollen, ROM achieved with audible clicking noise from joint. Recommend follow up treatment with Ortho.

Limits on basic work-related activities.

moderate

Patient ambulates with cane prescribed by PCP prior to losing medical insurance. Unable to get off exam table without assistance. Knee exam significant for swelling, visible scars from prior surgery, lateral laxity, and significantly reduced ROM. States Orthopedist recommended another surgery. Referring to Ortho today.

Significant limits on basic work-related activities.

marked

Patient brought to exam in a wheelchair by daughter. Both knees crushed in a car accident in 2009. Surgery improved functioning initially but trauma induced arthritis has progressed to the point patient can no longer walk more than a few feet with assistive devices. Exam positive for redness, swelling, extensive scar tissue and the appearance of bony deformities.

Unable to perform at basic work-related activities.

severe

 

Tyler applies for ABD cash and states back pain is keeping him from working.

Examination findings (chart notes)

Effect on work activities

Rating

Patient complains of intermittent back pain after heavy exertion or “sleeping on it wrong” pain resolves on its own within a day. ROM WNL. Advised patient to begin a moderate exercise program.

No effect on basic work-related activities.

1 (none)

Patient complains of frequent back pain aggravated by lifting and standing for extended periods of time. Relieved by NSAIDS and rest. Reduced ROM. Reflexes intact. Negative straight leg raise. No signs of radiculopathy. Mild degenerative changes and disc desiccation at L4 and L5. Referred for physical therapy.

No significant effect on basic work-related activities.

2 (mild)

Patient reports chronic pain aggravated by lifting, standing, and sitting for prolonged periods. Review of x-ray indicate moderate degenerative disc disease. Negative for weakness, numbness or tingling. Referring to ORTHO and cautioned patient not to do any heavy lifting.

Limits on basic work-related activities.

3 (moderate)

Patient reports weakness and concerned that he keeps dropping things. Positive for reduced sensation in extremities. Review of MRI positive for significant degenerate changes and moderate stenosis. Referring to ORTHO.

Significant limits on basic work-related activities.

4 (marked)

Patient arrives in wheelchair provided by VA. Has been unable to walk or stand since MVA last July. Condition is stable. Patient is wanting to find a PCP since he no longer lives near a VA clinic.

Unable to perform at least one basic work-related activity.

5 (severe)

 

Amy applies for ABD cash and states she can’t work because she has diabetes.

Examination findings (chart notes)

Effect on work activities

Rating

Well maintained on oral medication. Negative for vision changes, numbness, tingling, dizziness. All other systems WNL.

No effect on basic work-related activities.

1 (none)

Uncontrolled. Non compliant with diet and medication. Negative for retinopathy, numbness, tingling. Counseled patient on importance of diet and medication compliance to avoid significant complications.

No significant effect on basic work-related activities.

2 (mild)

Insulin dependent. Currently well controlled, Persistent peripheral neuropathy limits the time patient can walk and stand.

Limits on basic work-related activities.

3 (moderate)

Insulin dependent. Well controlled presently. Long term history of non compliance.  Advanced retinopathy. May be a candidate for laser surgery. Positive for reduced sensation in extremities.

Significant limits on basic work-related activities.

4 (marked)

Uncontrolled despite compliance with medication. Hospitalized with ketoacidosis twice this month. Positive for neuropathy in feet and retinopathy.

Unable to perform at least one basic work-related activity.

5 (severe)


NOTE:

Diagnostic uncertainty in the form of a provisional diagnosis is NOT acceptable for disability determinations. The person must provide evidence of a medically determinable condition.

Modification Date: December 12, 2011