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For Clinicians · Page 4 of 4

Page 4 of 4

Writing a Useful Opinion

Practical guidance for a DBQ narrative or nexus letter that actually gives a VA rater what they need — and avoids the most common reasons opinions get discounted or sent back for clarification.

✓ Helps the Claim

  • States an opinion using the probability language on Page 2 ("at least as likely as not," "less likely than not")
  • Names which theory you're addressing — direct causation, aggravation, or secondary connection
  • Explains your reasoning: what in the record, exam, or medical literature supports the conclusion
  • Addresses contrary evidence in the record, if you're aware of it, rather than ignoring it
  • Is specific to this veteran's facts, not a generic statement that could apply to anyone

✗ Gets Returned or Discounted

  • States a conclusion with no reasoning ("in my opinion, this is service-connected")
  • Uses only clinical-certainty language ("to a reasonable degree of medical certainty") without translating to the VA probability standard
  • Opines on the rating percentage or whether the claim should be approved
  • Treats "it's possible" as sufficient — possibility is a lower bar than VA's standard and doesn't meet it on its own
  • Says "cannot be determined without resort to speculation" without explaining what specific information is missing
A Useful Structure

Four Parts to a Solid Opinion

  1. Diagnosis: State the current diagnosis clearly, based on your exam or the record you reviewed.
  2. The question you're answering: Say explicitly whether you're addressing direct causation, aggravation, or a secondary connection (Page 3), and to which claimed condition or event.
  3. Your opinion, in VA's probability language: "It is at least as likely as not that..." or "It is less likely than not that..." — stated plainly, not buried in a paragraph.
  4. Your reasoning: The specific medical basis — exam findings, records reviewed, relevant medical knowledge, and how they connect to your conclusion. This is usually the part that's missing when an opinion is returned.
A short example: "It is at least as likely as not that the veteran's current lumbar strain is related to the documented 2009 in-service lifting injury. This is based on the continuity of lower back pain complaints in the service treatment records from 2009 through separation, the absence of any intervening injury in the civilian record, and the consistency of the current exam findings with a chronic strain pattern following the type of injury documented in service."

You don't need legal training to write this well — just a clear statement of which question you're answering, your conclusion in VA's probability terms, and the medical reasoning behind it.

← Causation vs. Aggravation

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