TN 2 (06-17)

A. General Record Requirements

In order to evaluate a mental impairment fully, the record must include evidence to establish both the existence of a medically determinable impairment (MDI) and the degree of limitation caused by the impairment.

1. Establishing an MDI

Establish the existence of a mental MDI with objective medical evidence from an acceptable medical source (AMS) consisting of signs, laboratory findings, or both. For mental impairments, laboratory findings may consist of psychological test results.

See DI 22505.003 for the list of AMSs.

See DI 22505.012 for guidance on how to handle claims in which the claimant has no medical source for the alleged mental impairment.

2. Assessing the severity of a mental impairment

Records from medical and nonmedical sources may be helpful in determining whether the claimant’s impairment results in work-related limitations for an adult or limits the ability to function independently, appropriately, and effectively in an age-appropriate manner for a child under age 18 for a Supplemental Security Income claim.

In order to assess impairment severity over time, evaluation of a mental impairment must take into account variations in the claimant’s functioning. Obtain evidence from relevant sources over a sufficiently long period to establish the claimant’s impairment severity on a regular and continuing basis.

See DI 22505.001 for further information on developing a complete medical history and DI 22505.006 for developing medical evidence outside of the applicable 12-month period.

NOTE: If the case has a Homeless Expedite flag, evidence may be available through a SSI/SSDI Outreach, Access, and Recovery (SOAR) program or other homeless service provider.

B. Sources of Functional Evidence

The general hierarchy of sources of functional information is as follows:

1. The claimant

2. The claimant’s own medical sources

3. Nonmedical sources (excluding past employers)

4. Past employers

5. Consultative examinations (CEs)

6. Work evaluations

   See DI 22515.010 for further information about work evaluations.

C. The Claimant as a Source

1. Information from the claimant on Form SSA-3368-BK

The field office (FO) will record sources of evidence on Form SSA-3368-BK (Disability Report—Adult). The FO will identify medical sources in “Section 8 – Medical Treatment” of the form, and nonmedical sources in “Section 2 – Contacts,” “Section 9 - Other Medical Information,” or “Section 11 – Remarks” of the form.

2. Disability Determination Services development

In addition to obtaining a complete medical history, it is critical to obtain information about the claimant’s day-to-day functioning from the claimant or other individual(s) familiar with the claimant’s daily activities.

See DI 22505.001 for further information on developing a complete medical history.

See DI 22511.011 for further information on collecting information about the claimant’s daily activities.

3. Evaluating information obtained from the claimant

Evaluate the information from the claimant to determine if it fits with the general pattern of the impairment as described by the medical evidence. The record should present a consistent picture of what the individual is able to do. See DI 24515.001C for further information about inconsistent case evidence.

If the medical evidence coupled with the claimant's statement(s) is not sufficient to document the severity of the impairment, consider whether recontact with the claimant can provide the necessary information. If claimant recontact is necessary, telephone contact with the claimant is the preferred method.

REMEMBER: If you establish a claimant failure or refusal to cooperate under procedures in chapter DI 23007.000, Failure to Cooperate, you may discontinue any development that requires claimant action (e.g., CEs and work evaluations).

D. Claimant’s own medical sources

1. Initial contact

The claimant’s medical sources are the best source of information to describe the claimant's functional capacities in terms of their clinical relevance. For more information on medical sources, see DI 22505.001 Medical and Nonmedical Evidence.

Ask the medical source(s) to provide information about how the claimant's impairment(s) limit his or her abilities in the paragraph B areas of mental functioning in the mental disorders listings: understand, remember, or apply information; interact with others; concentrate, persist, or maintain pace; and adapt or manage oneself.

2. Recontacting a medical source(s)

A medical source(s) may not submit detailed functional information in his or her initial response because he or she is not aware of the Social Security Administration disability program requirements or may not have recorded this information in the claimant's medical history. However, the source may have such information. You may need to recontact the medical source(s) to get the descriptive functional information necessary for proper evaluation of the case. Use of the telephone is the preferred method.

NOTE: If medical evidence is obtained by telephone, send the telephone report to the medical source for review, signature, and return. See DI 22505.030 Obtaining Medical Evidence by Telephone.

E. Nonmedical Sources

Examples of nonmedical sources include educational personnel, public and private social welfare agency personnel, family members, caregivers, friends, neighbors, employers, and clergy.

1. Preferred nonmedical source(s) for contact

Source(s) who are best able to provide the needed information are those who have observed the claimant on a long-term basis, are knowledgeable about the claimant's current day-to-day functioning, and can contrast this to the claimant's “premorbid” functioning if relevant. People either living with the claimant or those in close contact with the claimant are preferred.

2. Requesting information from a nonmedical source(s)

Elicit information from nonmedical sources who will help you get a clear picture of the claimant’s functioning on a day-to-day basis. Ask questions of these sources in such a way that you can secure objective and factual information.

NOTE: Inform the nonmedical source(s) you are seeking information in connection with a claim for Social Security benefits; however, take care to preserve the claimant's privacy in terms of not revealing that the claimant has a mental impairment. For more information, see GN 03316.005D for the policy of minimization when disclosing information to third parties.

F. Past Employers

In most cases, information from the claimant's past employer(s) is not necessary to permit an assessment of the claimant's functional limitations; however, there may be situations in which you should contact these sources.

NOTE: The information in this section is also applicable to present employer(s) if the claimant is currently working.

1. Contacting a past employer

Contact the claimant's past employer(s) only when the adjudicative team decides that more information is necessary and the claimant's past employer(s) would be a good source of the needed information. It may be necessary to contact past employers in cases where the individual is isolated and information from other identified sources is unavailable. Whenever possible, request this information from the claimant's immediate past supervisor.

2. Using information obtained from a past employer

Information from employers can be useful in establishing onset and determining whether the claimant is able to use each of the paragraph B areas of mental functioning in a work setting. Employers may also have information about the claimant’s functioning over time and any accommodations given to the claimant due to his or her functioning.

3. Considerations when evaluating information from a past employer

Past employers are not the primary choice for information concerning the areas of mental functioning. The information provided may be out of date or the period of employment may have occurred during a period in which the individual was temporarily functioning relatively well, or having an acute exacerbation of his or her condition, so it may not be relevant to the individual's baseline or current functioning.

However, particularly in cases where there have been frequent changes of employment and unsuccessful work attempts, information from past employers may be very revealing about the individual's capacity to tolerate stress and relate to co-workers and supervisors. Past employers may also be a good source of information if the claimant's condition has remained unchanged for an extended period.

G. Consultative Examinations (CE)

Make every effort to obtain functional information from the relevant sources as previously discussed. If the documentation in file is insufficient to make a determination or introduces conflict concerning impairment severity, considering ordering a CE.

NOTE: This discussion of CEs regards their utility as sources of functional evidence only. See DI 22510.005 When to Purchase a Consultative Examination (CE) for additional information about CEs.

H. Work Evaluations

Current work evaluations are necessary in relatively few cases. However, if a claimant has been in a vocational workshop or vocational training program, you must make a reasonable attempt to obtain this information.

1. When to purchase a vocational work evaluation

Consider purchasing a work evaluation to document functional limitations only after you have established a mental MDI and have secured:

1. All available medical evidence of record and evidence from CE sources; and

2. All available information about the claimant's daily and long-term functioning from the claimant and other knowledgeable persons.

If you have done all of the above and the evidence still is not sufficient to permit an assessment of the paragraph B areas of mental functioning or mental residual functional capacity, consider purchasing a work evaluation. For more information on when to purchase a work evaluation, see DI 22515.010 Use of Work Evaluations.