The rationale must discuss all the medical and nonmedical evidence used in the adjudicative process. Present the relevant symptoms, signs, and laboratory findings. For example, if there is a cardiac problem, discuss interpretation of available electrocardiograms (ECGs). Discuss both negative and positive findings. Do not discuss ECGs when there is no allegation or indication of a cardiac condition.

Adjudicators must give special attention to the evidentiary requirements of the listings related to the impairment(s). Use clear language; however, technical language may be required to document laboratory findings specified in a listing.

The discussion of the medical evidence in the rationale represents the core of the disability evaluation process. This section of the rationale will contain a discussion and summarization of the evidence including, as applicable:

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  Description of the findings with special attention to the evidentiary requirements of listings related to the impairment(s);

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  Discussion and resolution of any conflicts in the evidence;

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  Discussion of all allegations, including pain, and of all opinions to assess whether the evidence supports them; and

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  Explanation as to why a consultative examination (CE) was purchased.

Consideration of medical opinions depends on the filing date of the case. For claims with a filing date on or after March 27, 2017, follow the guidance in DI 24503.030, "Articulation Requirements for Medical Opinions and Prior Administrative Medical Findings – Claims filed on or after March 27, 2017." For claims filed before March 27, 2017, follow guidance in DI 24503.035, "Evaluation and Articulation Requirements for Medical Opinions, Opinions, and Prior Administrative Medical Findings – Claims filed before March 27, 2017."

Physicians and other acceptable medical sources (AMSs) are qualified as experts in matters pertaining to medicine and the evaluation of impairments. However, “disability,” as defined by the Social Security Act, encompasses not only the medical factors of impairment, but also the consideration of such nonmedical factors as age, education, past work experience, and daily activities.

Occasionally, a physician or other AMS may include conclusions or opinions in the medical records regarding the individual's abilities. When medical sources make statements about issues that are reserved to the Commissioner, regarding an individual’s abilities, such as “totally and permanently disabled,” “unable to work,” or “cannot return to any work,” the rationale must explain whether medical and nonmedical evidence substantiates these opinions. This explanation must describe any relevant program provisions, such as work incentives, and relate them directly to the adjudicator’s conclusions.

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  DI 24503.030 Articulation Requirements for Medical Opinions and Prior Administrative Medical Findings – Claims file on or after March 27, 2017

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  DI 24503.035 Evaluation and Articulation Requirements about Medical Opinions, Opinions, and Prior Administrative Medical Findings — Claims Filed before March 27, 2017

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  DI 24503.040 Evaluating Statements on Issues Reserved to the Commissioner (IRC)