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 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:
Section I, Summary Conclusions,
Section II, Remarks,
Section III, Functional Capacity Assessment and MC/PC signature.
The Heading provides space to record claimant and claim identification data.
2. Section I
Section I—Summary Conclusions is designed to record the MC/PC's analysis of the evidence and his/her conclusions about:
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/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/PC who conducted the analysis and prepared the mental RFC assessment.