A documented record shows that the determination is in conformance with applicable law. These instructions pertain to non-medical documentation. Medical documents will be in various e-Dib files. For notifying the DDS about non-medical information, see DI 11005.045

Unless another POMS section specifically requires that a paper copy be kept, record all non-medical evidentiary documents electronically using the following priority:

Documentation should reflect:

1. a. 

   Consideration for the claimant's due process rights;

2. b. 

   The opportunities provided to the claimant to submit evidence;

3. c. 

   A reasonable determination based upon the evidence in file;

4. d. 

   An adequate body of evidence;

5. e. 

   The electronic and paper versions of applications and other prescribed forms obtained including:

   • •

     Documents and records (e.g., prescribed MCS/MSSICS screens, EVID);

   • •

     Statements of claimants (e.g.,SSA-795, Remark (RMK)/Person Statement, or EVID per GN 00301.286E when MCS or MSSICS cannot be used);

   • •

     Statements of others (e.g., SSA 795, Report of Contact page in CCE, Report of Contact (RPOC), EVID);

   • •

     Personal observations of the interviewer or other pertinent information (e.g., Report of Contact page in CCE, RPOC or EVID per GN 00301.286E where MCS or MSSICS cannot be used);

   • •

     RPOC/Report of Contact page in CCE for Form SSA-553 (Special Determination) showing the adjudicator's evaluation of conflicting evidence or complex issues and inferences made;

   • •

     Prescribed questionnaires; and

   • •

     Other material as appropriate;

6. f. 

   Whether the documented record constitutes “substantial evidence” to support the determination; and

7. g. 

   Whether the documents in file are valid and authentic.

Failure to document the claims file in accordance with evidentiary standards established by SSA means the adjudicative decision is not properly supported by evidence and, thus, may be erroneous, and result in payment errors.

Common documentation errors are:

• •

  Omissions on applications, questionnaires, and other SSA forms;

• •

  Unidentified discrepancies/inconsistencies between SSA records (e.g. earnings record, MBR) and the claimant's allegations;

• •

  Absence of any evidence or insufficient evidence of a purported fact;

• •

  Acceptance of documents of questionable validity or authenticity, and improper certification of documents; and

• •

  Unexplained absence from the claims file of preferred evidence and reliance upon evidence of lesser probative value.

Document the claims file so that it fully supports the adjudicative decision.

• •

  Refer to the POMS instructions pertinent to the issue involved.

• •

  Document accordingly. Unless expressly permitted by POMS instructions, subsequent adjudicators/reviewers cannot make presumptions about information not documented in the claims file. Facts not recorded in the claims file cannot be considered as evidence.

• •

  A claims determination may be made based on a legal opinion pertaining to an individual State law. When this is the case, document which legal opinion was involved. See GN 01010.830B. when the opinion was issued for the specific case being adjudicated. See GN 01010.810 when a precedent opinion is used to adjudicate the claim.

• •

  When a claims determination is based upon a regional instruction, follow the guidelines in GN 00301.292.