What your examiner is actually documenting during your exam

For educational purposes only. Not medical treatment or legal advice.

An examiner’s job during a disability evaluation is to document specific things: the reported history, the clinical findings from the interview, the presence or absence of diagnostic criteria, and a rationale that connects those findings to the referral question. What a reviewer later reads is not a narrative of your visit; it is a structured record.

The four things a reviewer looks for

A reviewer reading a complete evaluation is checking, in order, for four things:

1. Who the evaluator is. Credentials, license, scope of practice, and whether the evaluator falls within the accepted category for the claim system.
2. What was reviewed. A list of source documents the evaluator saw before writing the opinion, cited by name and date, not by phrase.
3. What the examination consisted of. How long, in what format, and using what structured methods when applicable.
4. How the reasoning tracks. Whether each conclusion in the report is tied back to something documented in the file or the interview.

When any one of those four is missing, the opinion carries less weight in the file, regardless of what the opinion says.

Why “at least as likely as not” is not a slogan

For VA claims, the “at least as likely as not” phrase is a probability standard: a statement, expressed to a reasonable degree of medical certainty, that the connection is 50 percent or more likely than not. It is not a magic phrase. Writing it without a rationale that supports it is worse than not writing it at all, because a reviewer trained on these files will note the mismatch.

What you can do before an evaluation

You do not need to prepare for the interview the way you would for a job interview. What helps most is bringing the file into order: gather your DD214, your treatment records, and any prior decisions in one place, and be ready to answer specific questions about dates. Precision on dates, over confidence in the phrasing of your symptoms, is what actually helps the record.

Dr. Taylor English, Ph.D., is a licensed clinical psychologist and the founder of Provenance Evaluations. He trained at the James A. Haley Veterans’ Hospital in Tampa, Florida and at the Oklahoma City VA Health Care System.