Effective Dates: 04/17/2025 - Present Previous | Next

TN 39 (04-25)

DI 81020.110 Medical Evaluation

A. General – medical evaluation

In addition to following current policies and procedures pertaining to case review and medical evaluations, medical consultants (MC) and psychological consultants (PC) must evaluate electronic cases by reviewing imaged documents stored in the certified electronic folder (CEF).

B. Medical consultant and psychological consultant evaluation

1. Preparing Medical Assessment Forms

The disability examiner (DE), the MC, or the PC prepares the following medical assessment in the Disability Case Processing System (DCPS):

  • •

    SSA-538(Childhood Disability Evaluation Form (CDEF));

  • •

    SSA-416 Medical Evaluation

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    SSA-2506-BK (Psychiatric Review Technique (PRT));

  • •

    SSA-4734-F4 –

    (Physical Residual Functional Capacity (RFC) Assessment); and

  • •

    SSA-4734-F4-SUP (Mental Residual Functional Capacity (MRFC) Assessment).

The MC or PC must sign all medical assessment(s) using the approved electronic signature function.

NOTE: If completing the paper version of the medical assessment(s) in lieu of using DCPS, it must contain the hand-written (wet) signature of the MC or PC that completed the medical assessment(s) and be scanned into the CEF.

2. Modifying previously signed medical assessment on the same case

If, due to additional evidence being received, or other reason, a change is needed to a medical assessment(s) already signed (but before the case is closed by the DDS), unsign the medical assessment(s) to record the change and re-sign the medical assessment(s).

3. Using scanned tracings in medical evaluation

Images of tracings (electrocardiogram, pulmonary function study tracings, etc.) are acceptable to use for medical evaluation, even if the image somewhat distorts the actual scale, as long as the scale is displayed on the image and the grid lines are viewable. For more information about adding medical tracings to the CEF, see DI 81020.065.

C. Adopt medical assessments on reconsideration cases

The MC or PC may adopt any of the initial level medical assessment(s) when evaluating reconsideration cases. For more information on adopting medical assessments in reconsideration cases, see DI 81020.025D.

To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0481020110
DI 81020.110 - Medical Evaluation - 04/17/2025
Batch run: 04/17/2025
Rev:04/17/2025