DI 24510.060:
Mental Residual Functional Capacity Assessment
Effective Dates: 10/14/2010 - Present- Effective Dates: 07/02/2018 - Present
- DI 24510.060 Mental Residual Functional Capacity Assessment
- A. Operating Policy
- 1. Special Form
- Because of the complexity of mental disorder evaluation, a special Form SSA-4734-F4-SUP is to be used to document the mental residual functional capacity (RFC) decision, i.e., what an individual can do despite his /her impairment.
- 2. Medical Consultant Completion
- * Unfavorable and Partially Favorable Decisions
- In decisions that are not fully favorable, only a psychiatrist or psychologist is to perform the analysis and decide the mental functional capacity.
- * Fully Favorable Decisions
In fully favorable determinations, the medical consultant (MC) who completes the mental RFC assessment, to the extent possible, should be a psychiatrist or psychologist.- In fully favorable determinations, the medical or psychological consultant (MC/PC) who completes the mental RFC assessment, to the extent possible, should be a psychiatrist or psychologist.
- * When Physical Impairment Involved
- Refer the claim to a physician of the appropriate medical specialty after all mental RFC considerations have been accomplished.
- B. Description of Form SSA-4734-F4-SUP
- Form SSA-4734-F4-SUP is divided into four sections:
- * Heading,
- * Section I, Summary Conclusions,
- * Section II, Remarks,
* Section III, Functional Capacity Assessment and MC signature.- * Section III, Functional Capacity Assessment and MC/PC signature.
- 1. Heading
- The Heading provides space to record claimant and claim identification data.
- 2. Section I
Section I—Summary Conclusions is designed to record the MC's analysis of the evidence and his/her conclusions about:- Section I—Summary Conclusions is designed to record the MC/PC's analysis of the evidence and his/her conclusions about:
- * the presence and degree of specific functional limitations, and
- * the adequacy of documentation.
- * Section I is merely a worksheet to aid in deciding the presence and degree of functional limitations and the adequacy of documentation and does not constitute the RFC assessment.
- * Twenty mental function items are grouped under four main categories:
- * Understanding and Memory,
- * Sustained Concentration and Persistence,
- * Social Interaction, and
- * Adaptation
- * To the right of each of the items is a series of decision checkblocks under the headings:
- * Not Significantly Limited
- * Moderately Limited
- * Markedly Limited
- * No Evidence of Limitation in This Category, and
- * Not Ratable on Available Evidence
- 3. Section II
- Section II - Remarks, provides for discussion of evidence needed to rate particular items in section I.
- 4. Section III
- * Section III—Functional Capacity Assessment, is for recording the mental RFC determination. It is in this section that the actual mental RFC assessment is recorded, explaining the conclusions indicated in section I, in terms of the extent to which these mental capacities or functions could or could not be performed in work settings.
- * The discussion of all mental capacities and limitations in this section must be in narrative format.
The MC must also include any other information that he/she believes is necessary to present a complete picture of mental RFC.- The MC/PC must also include any other information that he/she believes is necessary to present a complete picture of mental RFC.
- * The Narrative must not present estimates of capacities for mental functions that could not be rated because of insufficient evidence. Such would represent speculation.
* The completed SSA-4734-F4-SUP must be signed by the MC who conducted the analysis and prepared the mental RFC assessment.- * The completed SSA-4734-F4-SUP must be signed by the MC/PC who conducted the analysis and prepared the mental RFC assessment.
x
← This means that the line
was removed and
was added – in other words, the "Effective Dates" line at the top of the document has been updated to reflect that the new version is effective as of the date the change was made.