What type of information should be included in the medical report for a patient?
Your report should include the history and clinical and laboratory findings, as well as the diagnosis and treatment prescribed and the response to treatment–as much objective information from the patient’s chart as possible. You also should include a statement about what work activities the patient can still do despite his/her impairment. 15. How important is my statement about what my patient can still do? Your statement about what work activities the patient can still do despite his/her impairment, based on the history and clinical and laboratory findings that you provide, can be very important to the decision on whether your patient is disabled as defined by the law. We will generally give much more weight to the opinion of a physician or other medical source who is treating the patient on a continuing basis, and we will give controlling weight to such an opinion if it is well supported by the clinical and laboratory findings and is not inconsistent with any other evidence in the p
