TN 49 (09-96)
The RFC Assessment Process:
evaluates and interprets medical and other evidence.
makes findings of fact about work-related functional capacities.
documents the findings of fact and the supporting evidence.
General
The medical consultant (MC) or psychological consultant (PC) has overall responsibility for assessment of RFC.
NOTE: The PC may assess mental RFC but may not assess physical RFC.
Mental Impairment Involved
Denial Indicated—A qualified psychiatrist or psychologist must assess the mental RFC.
Allowance Indicated—Every reasonable effort must be made to have a qualified psychiatrist or psychologist assess the mental RFC.
NOTE: See DI 24510.001A.2.b. for disability hearing cases.
The RFC assessment is recorded on:
The SSA-4734-U8 for physical impairments. (See DI 24510.055.)
The SSA-4734-F4-SUP for mental impairments. (See DI 24510.090.)
The disability examiner may assist in completion of the RFC assessment forms. However, the MC or PC, as appropriate, must sign the SSA-4734-U8 or SSA-4734-F4-SUP to attest that he/she is responsible for its content, including the findings of fact and discussion of supporting evidence.
Be sure the file contains sufficient evidence to assess RFC.
Assess functional capacity based on all relevant evidence in file (medical history, medical signs and laboratory findings; observations; symptoms, such as pain; medical opinions; report of daily activities; lay evidence; etc.).
Consider and respond to any alleged limitations imposed by symptoms, including pain, attributable to a medically determinable impairment.
Consider and respond to all allegations of physical and/or mental limitations or factors which could cause physical and/or mental limitations.
Express the assessment in terms of the claimant'sability to perform work-related functions.
Address each function separately.
Do not generalize the RFC assessment in terms of sedentary, light, medium, or heavy levels of work.
Describe how the evidence supports each conclusion. (Cite the specific medical and nonmedical facts.)
NOTE: The functional restrictions recorded on the SSA-4734-U8 must be related to a medically determinable impairment and must not reflect consideration of the individual's normal physiological makeup.
Evaluate and base your conclusions on all facts of the case, including (but not limited to):
the history
the objective medical test results and physical findings
the characteristic effects of the disease or disorder
the effects of treatment
reports of daily activities
lay evidence (e.g., statements of claimants and others)
recorded observation
the effects of symptoms
precipitating and aggravating factors for fatigue
Consider an 8-hour workday and a 5 day work week (with normal breaks, e.g., lunch, morning and afternoon breaks) in evaluating the ability to sustain work-related functions.
Where there is no allegation, documentation, or indicationof specific physical or mental limitations, consider the individual to have no limitations with respect to those capacities.