DI 24510.005:
General Guidelines for Residual Functional Capacity (RFC) Assessment
Effective Dates: 08/09/2012 - Present- Effective Dates: 07/10/2018 - Present
- TN 49 (09-96)
- DI 24510.005 General Guidelines for Residual Functional Capacity (RFC) Assessment
- A. Process
- The RFC Assessment Process:
- * evaluates and interprets medical and other evidence.
- * makes findings of fact about work-related functional capacities.
- * documents the findings of fact and the supporting evidence.
- B. Policy
- 1. Responsibility for Assessing RFC
- * General
- The medical consultant (MC) or psychological consultant (PC) has overall responsibility for assessment of RFC.
- NOTE: The PC may assess mental RFC but may not assess physical RFC.
- * Mental Impairment Involved
- * Denial Indicated—A qualified psychiatrist or psychologist must assess the mental RFC.
- * Allowance Indicated—Every reasonable effort must be made to have a qualified psychiatrist or psychologist assess the mental RFC.
- NOTE: See DI 24510.001A.2.b. for disability hearing cases.
- 2. Recording the RFC Determination
- * The RFC assessment is recorded on:
- * The SSA-4734-U8 for physical impairments. (See DI 24510.055.)
- * The SSA-4734-F4-SUP for mental impairments. (See DI 24510.090.)
- * The disability examiner may assist in completion of the RFC assessment forms. However, the MC or PC, as appropriate, must sign the SSA-4734-U8 or SSA-4734-F4-SUP to attest that he/she is responsible for its content, including the findings of fact and discussion of supporting evidence.
- C. Procedure
- 1. General
- * Be sure the file contains sufficient evidence to assess RFC.
* Assess functional capacity based on all relevant evidence in file (medical history, medical signs and laboratory findings; observations; symptoms, such as pain; medical source statements; report of daily activities; lay evidence; etc.).- * Assess functional capacity based on all relevant evidence in file (medical history, medical signs and laboratory findings; observations; symptoms, such as pain; medical opinions; report of daily activities; lay evidence; etc.).
- * Consider and respond to any alleged limitations imposed by symptoms, including pain, attributable to a medically determinable impairment.
- * Consider and respond to all allegations of physical and/or mental limitations or factors which could cause physical and/or mental limitations.
- * Express the assessment in terms of the claimant'sability to perform work-related functions.
- * Address each function separately.
- * Do not generalize the RFC assessment in terms of sedentary, light, medium, or heavy levels of work.
- * Describe how the evidence supports each conclusion. (Cite the specific medical and nonmedical facts.)
- NOTE: The functional restrictions recorded on the SSA-4734-U8 must be related to a medically determinable impairment and must not reflect consideration of the individual's normal physiological makeup.
- 2. Stamina and Endurance
- * Evaluate and base your conclusions on all facts of the case, including (but not limited to):
- * the history
- * the objective medical test results and physical findings
- * the characteristic effects of the disease or disorder
- * the effects of treatment
- * reports of daily activities
- * lay evidence (e.g., statements of claimants and others)
- * recorded observation
- * the effects of symptoms
- * precipitating and aggravating factors for fatigue
- * Consider an 8-hour workday and a 5 day work week (with normal breaks, e.g., lunch, morning and afternoon breaks) in evaluating the ability to sustain work-related functions.
- 3. No Alleged Limitations
- Where there is no allegation, documentation, or indicationof specific physical or mental limitations, consider the individual to have no limitations with respect to those capacities.
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