Disability chronology sample: lumbar stenosis and COPD
Answer in brief: a Social Security disability chronology is organized around function over time. Each row counts months from the alleged onset date, marks whether the fact is an exam finding, a test result, a reported symptom or an opinion, and puts conflicting statements about the same ability next to each other. This sample shows it on a 148-page synthetic file, no real patient.
Limits: Every sample here is synthetic: no real patient, invented names and invented page numbers. Rules quoted for QME and Social Security work come from the cited regulation, read 2026-11-12; they are not legal advice, and facts about other sample libraries come from each publisher's page on that date.
The synthetic file
| Claimant | Patient D, 57, forklift operator for 22 years. Invented. |
|---|---|
| Alleged onset date | 2024-03-01, the last day worked |
| Conditions claimed | Lumbar spinal stenosis with leg pain on walking; chronic obstructive pulmonary disease |
| Who reads it | A treating physician writing a medical source statement, a consultative examiner, or a physician reviewing the file for a claimant's representative |
| File | 148 pages from 9 sources: primary care, imaging, pulmonary function lab, pain management, neurosurgery, pulmonology, emergency department, the consultative exam, and the work history report |
The sample disability chronology
13 rows across 22 months. "Mo" is months from the alleged onset date (negative before it). "Basis" says what kind of fact the row holds.
| Date | Mo | Source | What the record says | Basis | Page | Note |
|---|---|---|---|---|---|---|
| 2023-10-05 | -5 | S. Whitfield, MD, primary care | Back and leg pain after walking "more than 2 blocks", relieved by sitting. Strength 5/5 legs. | Reported; exam | 9-11 | Prior A1 |
| 2024-01-22 | -1 | Mesa Imaging | MRI lumbar: "severe central canal stenosis L4-5, moderate L3-4." | Test | 30-31 | Verbatim |
| 2024-03-01 | 0 | Claimant | Work history report: stopped work; "could not get on and off the forklift all shift." | Reported (non-medical) | 3 | Onset A2 |
| 2024-03-18 | 0 | Pulmonary function lab | Spirometry: FEV1 1.62 L, 54 percent of predicted; FEV1/FVC 0.58. | Test | 40-42 | |
| 2024-04-29 | 1 | N. Osei, MD, pain management | L4-5 epidural steroid injection. | Procedure | 55-57 | |
| 2024-06-10 | 3 | S. Whitfield, MD, primary care | "Walks 1 block before leg pain." Uses a cane "bought himself." Injection helped "about 2 weeks." | Reported | 60-62 | Cane A3 |
| 2024-08-21 | 5 | H. Lam, MD, neurosurgery | Offers L3-5 decompression. Claimant defers pending lung clearance. Exam: "wide-based gait, unable to heel walk." | Exam; plan | 70-74 | |
| 2024-10-02 | 7 | R. Duarte, MD, pulmonology | 6-minute walk 290 m, oxygen saturation fell to 88 percent. On 2 inhalers. | Test | 80-84 | |
| 2024-12-05 | 9 | Mesa Regional ED | COPD exacerbation. Discharged on prednisone. | Exam | 90-96 | |
| 2025-02-11 | 11 | S. Whitfield, MD, primary care | Medical source statement: stand and walk under 2 hours in an 8-hour day; lift 10 lb occasionally; must change position every 30 minutes. Cites the MRI and the 6-minute walk. | Opinion | 101-103 | Supportability A4 |
| 2025-03-04 | 12 | Consultative examiner, internal medicine | "Walked 50 feet without the cane, slow but steady." Straight leg raise negative. No pulmonary testing done. | Exam | 110-115 | Conflict with 2024-06-10 A5 |
| 2025-05-20 | 14 | H. Lam, MD, Mesa Regional | L3-5 laminectomy after pulmonary clearance. No complications. | Procedure | 130-136 | |
| 2025-08-26 | 17 | H. Lam, MD, neurosurgery | "Leg pain much improved, walks 4 blocks." Back pain persists. Lift limit 20 lb. | Reported; exam | 140-142 | Change after 17 months A6 |
Annotations: why each row reads the way it does
- A1, records before onset still count. The 2023 note shows the walking limit began before the claimant stopped work. A disability chronology starts where the condition starts, not on the alleged onset date.
- A2, the onset row is the anchor. Every row's month count is measured from here. Social Security requires that the impairment "must have lasted or must be expected to last for a continuous period of at least 12 months" (20 CFR 404.1509, read 2026-11-12). The Mo column lets a reader see that span without date math.
- A3, record how a device came to be used. "Bought himself" is quoted because a reader will want to know whether a clinician prescribed the cane or the claimant chose it. The row does not judge either.
- A4, opinions get the Opinion tag and their support. Under 20 CFR 404.1520c, supportability and consistency are the most important factors in how persuasive a medical opinion is. The row says which findings the opinion cites, so a reader can check supportability without opening the statement.
- A5, conflicting observations sit side by side. 50 feet observed without a cane and 1 block reported with a cane are both in the file. The row names the earlier row it conflicts with and notes that no pulmonary testing was done at the exam. Consistency is the decision maker's call; the chronology makes the comparison possible.
- A6, show improvement as plainly as decline. The 17-month row records better walking after surgery and the remaining limits. A chronology that stops at the worst point misleads every reader, whichever side they are on.
The Basis column
The federal rules say that "statements about your pain or other symptoms will not alone establish that you are disabled" (20 CFR 404.1529, read 2026-11-12). That is why this sample splits facts into 5 kinds: exam (what a clinician observed), test (imaging, spirometry, walk tests), reported (what the claimant said), procedure, and opinion. A treating physician writing a source statement can use the column to cite findings rather than reports. A reviewer can use it to see at a glance whether a limit rests on testing or on history alone.
What a disability chronology adds to a base table
- Months from onset on every row, so the 12-month span is visible.
- The Basis column, separating exam, test, reported and opinion.
- Function in the row text: distances, weights, times, positions. Diagnoses alone say little about what a person can do.
- Every condition in 1 table. Back and lung rows sit together because their limits combine. The neurosurgery plan waited on lung clearance; separate tables would hide that.
Common misses in disability chronologies
- Starting at the onset date and dropping the history that leads up to it.
- Reporting "chronic back pain" with no distances, weights or durations.
- Leaving out the consultative exam because it cuts the other way.
- Treating a source statement as a finding instead of an opinion.
- Splitting conditions into separate chronologies, so their combined effect never shows.
Questions about disability chronology samples
Should a disability chronology include records from before the onset date?
Yes, when they show the same condition. They show how the impairment developed and can support the onset date.
Why mark reported symptoms differently from exam findings?
Because the federal rules say symptoms alone do not establish disability. Readers need to see which limits rest on findings or tests and which rest on history.