TN 2 (08-15)

DI 28090.035 Rationale Content - Medical Findings

A. Discussion of medical findings

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 ECGs, but do not discuss ECGs when there is no allegation or indication of a cardiac condition. Discuss both negative and positive findings.

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 specific 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:

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

  • a discussion and resolution of any conflicts in the evidence;

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

  • an explanation as to why a consultative examination (CE) was purchased, when applicable.

B. Medical opinions — Claims filed before March 27, 2017

Physicians, and other acceptable medical sources, 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 acceptable medical source 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.

C. References

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

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


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http://policy.ssa.gov/poms.nsf/lnx/0428090035