Effective Dates: 03/09/2026 - Present Previous | Next

TN 5 (03-26)

DI 26515.001 Documenting the Rationale in Adult Initial Claims

CITATIONS:

20 CFR 404.1501 through 404.1585, Part 404, Subpart P, Appendix 2, and 416.901 through 916.985
Social Security Rulings (SSR) 13-2p, 16-3p, and 18-3p.

A. Policy overview

The Disability Determination Services (DDS) are required to fully document their analysis of case facts and material issues in a clear and cohesive rationale.

Rationale requirements include:

  • •

    Thorough, evidence-based documentation;

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    Compliance with applicable agency policies and standards; and

  • •

    Support for the sequential evaluation process findings that lead to the conclusion of "disabled" or "not disabled."

The DDS will use the Disability Determination Explanation (DDE) to organize this information so that the analysis is clear to subsequent reviewers.

B. Elements of the rationale

Not every claim requires a discussion of all possible elements of the rationale. This section explains how to document the elements of the rationale based on the case facts to form a persuasive explanation of the disability determination.

IMPORTANT: Do not duplicate explanations in multiple sections of the DDE. Whenever possible, use the designated section to discuss each specific issue within the context of applicable policy to ensure that subsequent reviewers can easily locate and understand your analysis.

1. Allegations of impairment

The DDS will review the claimant's alleged impairments, correct any misspellings, and document new allegations reported during case development. When a claimant alleges a new impairment, the DDS will use existing procedures to develop all relevant evidence, as explained in DI 22501.001 and DI 22505.008.

When a new condition is discovered during case development that was not alleged, the DDS will use the procedures in DI 24505.030C to determine whether the discovered condition is a medically determinable impairment (MDI) and, if so, the DDS will add it to the claimant's established MDIs.

For information on establishing an MDI, see DI 24501.020.

For information on potential impairments, see DI 24505.030.

2. Technical issues

When the DDS identifies a technical issue(s), such as those listed below, they will discuss their effect on the claim and explain how the issue was resolved.

3. Evidence

The DDS will:

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    Follow existing policy to request all medical and non-medical evidence (see DI 22505.001A, DI 22505.006, and DI 22511.007);

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    Follow up on requests for evidence and document these efforts. (For information on how to follow up on requests for medical evidence, see DI 22505.035. For information on how to follow up on requests for evidence or action from a non-medical source, see DI 22505.014);

  • •

    Cite the source of the evidence and the date the evidence is received. For CE reports, cite the CE source and the date of the examination; and

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    Document the reason for not requesting evidence from a medical source, when applicable (see DI 22505.006A.3).

IMPORTANT: Before requesting evidence, consider whether any of the procedures discussed in DI 22505.006B.1. are applicable (e.g., prior folder evidence).

4. Case note

The DDS will use a case note to document contact with individuals or entities relevant to the case, or to explain issues that do not require documentation elsewhere. When the subject of a case note is material to the determination (e.g., vocational analysis), the DDS must "write" the case note to the DDE. When the subject of a case note is not material to the determination (e.g., documenting claimant contact or consultative examination development), the DDS will "write" the case note to the Case Development Worksheet (CDW).

5. Findings of fact and analysis of evidence (FOFAE)

The DDS will use the FOFAE to document and explain how they considered all of the relevant evidence in the folder. Rather than only listing findings or restating evidence, the DDS is expected to use the FOFAE to:

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    Document and explain relevant medical findings, such as demonstrating that an MDI meets or equals a specific listing and referencing the findings that supports the DDS's conclusion;

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    Discuss their analysis of the case facts;

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    Explain how they used adjudicative judgment to resolve an issue;

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    Document the basis for FSF findings and which evidence to disregard, when applicable (see DI 23025.025)

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    Address any other issues related to evidence evaluation not discussed in other dedicated sections of the rationale. For example, when evidence from a non-medical source (e.g., a teacher questionnaire) is material to other analyses or conclusions in a claim, articulate that in the determination (see DI 24503.020D.1.)

6. Medical evaluation

The medical evaluation is the agency's explanation of the medical determination and must address the alleged and discovered impairments for the full assessment period on one or more medical assessment forms. Every disability determination must contain a medical evaluation unless the case contains no medical evidence (see DI 24501.002).

The disability examiner (DE) may assist with completing the medical assessment form however only a medical or psychological consultant (MC/PC) may sign the medical assessment form (see DI 24501.001).

a. MDI

The DDS will document all MDI(s) and indicate whether the MDI is severe or not severe.

For information on establishing an MDI, see DI 24501.020.

b. Symptom evaluation

The DDS must use the two-step symptom evaluation process to:

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    Document whether the claimant has an MDI that could reasonably be expected to produce the alleged symptoms; and

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    Evaluate the intensity and persistence of the claimant’s symptoms to determine the extent to which they limit the claimant’s ability to perform work-related activities (for an adult) or function independently, appropriately, and effectively in an age-appropriate manner (for a child with a Title XVI disability claim). This includes analyzing and explaining the extent to which the symptoms are consistent or inconsistent with all the case evidence.

When completing the narrative symptom evaluation, do not use mere boilerplate language or single conclusory statements, such as "the individual's symptoms have been considered" or "the individual's statements of symptoms are/are not supported by the case evidence."

NOTE: When it is possible to make a fully favorable determination based solely on the objective medical findings, adjudicators do not need to consider symptoms in the medical evaluation UNLESS they are identified as one or more criteria in the listing. For more information on curtailing development for a fully favorable determination, see DI 24515.020.

c. Medical opinions

The DDS will review the evidence for any medical opinions. How the adjudicative team considers the medical opinions depends on the filing date of the claim. For claims with a filing date on or after March 27, 2017, follow DI 24503.030. For claims filed before March 27, 2017, follow DI 24503.035.

When documenting the medical opinion:

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    Cite the opinion source(s) and date;

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    Describe the content of the opinion;

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    For claims filed on or after March 27, 2017, evaluate the persuasiveness of the opinion, explaining how the MC or PC considered the supportability and consistency of the opinion, and any other factors, per DI 24503.025E;

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    For claims filed before March 27, 2017, weigh the opinion evidence per DI 24503.035; and

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    Provide an explanation for findings that are less restrictive than the medical opinion.

d. Listing of impairments

For each MDI, the DDS will document the listing considered that best corresponds with the MDI(s).

For information on the Listings, see DI 34001.000.

e. Medical evaluations and assessments

The MC or PC, or both, completes the appropriate medical evaluation or assessment, such as the:

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    SSA-416 (Medical Evaluation) (see DI 24501.006);

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    SSA-4734-BK (Physical Residual Functional Capacity Assessment) (see DI 24510.050);

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    SSA-2506-BK (Psychiatric Review Technique (PRT)) (see DI 24583.005);

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    SSA-4734-F4-SUP (Mental Residual Functional Capacity Assessment) (see DI 24510.060)

f. Failure to follow prescribed treatment (FTFPT)

When FTFPT is a material issue, explain its relevance to the determination. For information on FTFPT, see DI 23010.000.

g. Adult medical disposition

Apply the adult medical disposition that corresponds with the completed medical assessment:

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    Meets listing (see DI 24508.005);

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    Medically equals listing (see DI 24508.010);

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    RFC assessment necessary (see DI 24510.000);

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    No work profile (see DI 25010.001B.2);

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    Insufficient evidence (see DI 23007.015C);

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    Does not meet the duration requirement (DI 25505.000);

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    Res judicata (see DI 27516.000);

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    Other.

h. Overall medical signature

The DE will apply the signature of the MC or PC who takes responsibility for the determination (see DI 24501.001B.4.).

7. Vocational assessment

If the analysis proceeds beyond step three of the sequential evaluation process, the DDS must assess whether the claimant retains the ability to perform their past relevant work (PRW) at step four or adjust to other work at step five and document the findings.

Generally, a detailed work history is needed to complete the vocational assessment. For information on whether a detailed work history is required to complete the vocational assessment, see DI 22515.003 and DI 22515.010.

a. PRW

The DDS documents all PRW including job title, start and end date, whether the PRW is relevant, and the Dictionary of Occupational Titles (DOT) information. For information about development and capacity to do PRW, see DI 25005.000.

NOTE: If an expedited vocational assessment is appropriate, select the check box that indicates this type of assessment in the Disability Case Processing System (DCPS) before proceeding. For information on expedited vocational assessments, see DI 25005.005.

b. Medical-vocational guidelines

When the claimant is unable to perform their PRW as described or as generally performed in the national economy, the DDS must apply the appropriate vocational rule from the table in DI 25025.035 and indicate whether the vocational rule directs a determination of disabled or not disabled or is used as a framework for a determination. For information on the medical-vocational guidelines and how to determine which rule to use as a framework for a determination, see DI 25025.000.

IMPORTANT: When the claimant's exertional capacity falls between rules resulting in different outcomes, always document and explain the basis of your conclusions.

If necessary, consult a Vocational Specialist (VS) to determine which rule most closely approximates the claimant's RFC and vocational factors of age, education, and past work experience. For information on when to use a VS, see DI 25003.001C.

c. Other work findings

When the DDS uses a medical-vocational rule as a framework, they must support their findings by citing one of the following:

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    Up to three occupations for which there are a significant number of jobs that exist in the national economy;

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    The appropriate SSR; or

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    The appropriate exception.

When transferability of skills is a material issue, the DDS must provide a Transferability of Skills Assessment (TSA). For information on the TSA process and documentation, see DI 25015.018 and DI 25015.019.

8. Disability determination

a. Acquiescence rulings

When an acquiescence ruling applies, the DDS must document:

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    Which ruling applies;

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    The action the DDS took; and

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    How the ruling affects the claim.

If no acquiescence ruling applies, select "None of the ARs considered apply to this claim" in DCPS. For information on acquiescence rulings, see DI 52700.000.

b. Drug addiction and alcoholism (DAA)

When medical evidence from an AMS establishes a substance abuse disorder and the DDS finds the claimant disabled, the DDS must decide whether DAA is a factor material to the determination of disability. The DDS must explain that materiality finding in the determination or in other appropriate documents, such as the RFC assessment form, as explained in SSR 13-2p. For information on DAA, see DI 90070.000.

c. Determination

Based on the documented findings, the DDS will apply the appropriate determination from the following list:

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    Not disabled;

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    Disabled;

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    No determination; or

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    Transfer

NOTE: The DDS must document the reason when selecting "no determination" or "transfer." For information on processing a "no determination," see DI 81020.127.

d. Regulation basis code (RBC)

The DDS will document the RBC most consistent with the disability determination (e.g., not severe, meets a listing, etc.). For information on RBCs, see DI 26510.045.

e. Allowance information

  1. 1. 

    Established onset date (EOD)

    When processing a favorable allowance, the DDS is responsible for establishing and documenting the EOD. If the EOD is different from the POD, the DDS must explain the reason(s) for the change. For information on onset, see DI 25501.000.

  2. 2. 

    Closed period

    When the allowance determination is for a closed period of disability, the DDS must articulate its finding of medical improvement (MI) under the medical improvement review standard (MIRS), or identify the applicable exception to the MIRS, and specify the date disability ceased. The DDS may not determine that a period of disability ends due to SGA. For information on a closed period of disability, see DI 25510.001. For information on how to apply the MIRS and the MIRS exceptions, see DI 28005.001.

  3. 3. 

    Diary

    The DDS will establish and document the appropriate diary based on the likelihood of MI of the disabling MDI(s). For more information on diaries, see DI 26510.020.

  4. 4. 

    Capability

    When developing capability (i.e., the FO identifies an issue or the evidence indicates a capability finding is needed), the DDS will document whether capability is resolved or unresolved. For information on procedures for documenting capability, see DI 23001.015.

9. Review and sign

The DE must apply their signature to the claim before case closure. For information on the signature responsibilities of the DE, see DI 24501.001B.2.

10. Case Closure

At case closure, the DDS will upload the DDE to Section A (Payment Documents/Decisions (Yellow Front)) of the Certified Electronic Folder (CEF) for each title under which a claimant applied for benefits or payments.

To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0426515001
DI 26515.001 - Documenting the Rationale in Adult Initial Claims - 03/09/2026
Batch run: 03/09/2026
Rev:03/09/2026