Medical/Professional Relations

Consultative Examinations: A Guide for Health Professionals

Part IV - Adult Consultative Examination Report Content Guidelines

The following are guidelines for minimum content requirements for CE reports on adult claimants. Each DDS will notify medical sources of any additional requirements.

A complete CE is one that involves all the elements of a standard examination in the applicable medical specialty. When the report of a complete CE is involved, the report should include the following elements:

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Internal Medicine

The detail and format for reporting the results of the history, physical examination, laboratory findings, and discussion of conclusions should follow the standard reporting principles for a complete internal medical examination.

1. Source of History
    
   The medical source should indicate from whom the history was obtained and should provide an estimate of the reliability of the history.
    
2. History of Present Illness
    
   1. The chief complaint(s) alleged as the reason for not working should be discussed in detail, including:
       
      1. Factors which increase the problem or impairment(s);
          
      2. How long the problem has been present;
          
      3. Factors which may provide relief; and
          
      4. The claimant's description of how the impairment(s) limits the ability to function.
          
   2. Pertinent descriptive statements by the claimant, such as a description of chest pain, should be recorded in the claimant's own words.
       
   3. The information must be in a narrative, rather than "questionnaire" or "check-off" format.
       
3. Past History should describe other prior illnesses, injuries, operations, or hospitalizations and give the dates of these events.
    
4. Current Medication should be listed by name of drug and dose.
    
5. Review of Systems should describe and discuss:
    
   1. Other complaints and symptoms the claimant has experienced relative to the specific organ systems, and
       
   2. The pertinent negative findings, which would be considered in making a differential diagnosis of the current illness or in evaluating the severity of the impairment.
       
6. Social History should include pertinent findings about use of tobacco products, alcohol, nonprescription drugs, etc.
    
7. Family History should be presented, if pertinent.
    
8. Signs
    
   1. The vital signs should include:
       
      1. Blood pressure;
          
      2. Pulse rate;
          
      3. Respiratory rate; and
          
      4. Height and weight without shoes.
          
   2. The physical examination must provide a description of the claimant's general appearance and pertinent behavior during the examination (e.g., for back complaint, how the claimant stood or walked, got up from a chair, and got on and off the examination table).
       
      1. This description must be in narrative, rather than "questionnaire" or "check-off" form.
          
      2. The report should present aspects of the examination dealing with the claimant's major and minor complaints in particular detail, describing both pertinent negative and positive findings.
          
   3. Pelvic examinations should not be performed unless specifically authorized.
       
   4. Specific range of motion of a joint should be reported in degrees for joints in which there is a significant limitation of motion.
      
      NOTE: If a joint is found to have no abnormality of range of motion on gross examination, that fact should be stated rather than reporting the degree of motion.
       
9. Laboratory Tests -- The laboratory should provide:
    
   1. Actual values for laboratory tests; and
       
   2. Normal ranges of values in either the medical report or attached laboratory report.
       
   3. Electrocardiographic and Spirographic Reports
       
      1. Tracings must be provided when these tests have been performed.
          
      2. The reported findings for pulmonary and electrocardiographic studies must meet the  requirements of Section 3.00E and 4.00C, respectively, of the Listing of Impairments.
          
   4. Interpretation
       
      1. The interpretation of laboratory tests (e.g., electrocardiographic tracings) must take into account and be correlated with the history and physical examination findings.
          
      2. Identify the medical source providing the formal interpretation of the laboratory tests, when other than the medical source who is signing the CE report.
          
      3. If the interpretation is provided separately, the report sheet should state the interpreting medical source's name and address.
          
   5. X-rays
       
      Joints and other areas to be x-rayed are those that are specifically requested or those that the physical examination reveals to be the most involved by disease, after appropriate authorization by the DDS.
       

Rheumatology

In addition to the requirements for a general internal medical examination, the following specific information should be stated in a report of an examination in which the primary complaint is a rheumatological disorder.

1. General Observations
    
   General observations in the physical examination should relate to common, everyday functions which may be observed in the examining medical source's office, such as:
    
   1. Stance;
       
   2. Gait;
       
   3. Ability to:
       
      1. Dress and undress;
          
      2. Climb upon the examining table;
          
      3. Grasp or shake hands; and
          
      4. Write.
          
2. Joint Examination
    
   1. Joint examination should include specific, detailed notations with respect to the presence or absence of:
       
      1. Effusion;
          
      2. Episodes of infection;
          
      3. Periarticular swelling;
          
      4. Tenderness;
          
      5. Heat;
          
      6. Redness;
          
      7. Thickening of the joints;
          
      8. Specific range of motion of the joints and back in degrees; and
          
      9. Structural deformities.
          
   2. Specific range of motion of a joint or spine should be reported in degrees for any joint or spine in which there is a significant limitation of motion.
       
   3. If the range of motion is found to be restricted in any joint or spine, annotation should be made as to probable cause (e.g., due to pain and/or influenced by observable abnormality).
       
   4. Joints/spine to be x-rayed are those that are specifically requested or those that the physical examination reveals to be the most involved by disease, after appropriate authorization by DDS.
       
3. For individuals alleging myalgias or other muscular complaints, evaluate the areas of muscle tenderness including tender points and trigger points.

Go to Listing of Impairments - Adults: Immune System 14.00 for more information.

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Orthopedic

1. History
    
   The orthopedic examination, including the lumbar and cervical spine, should describe and discuss
    (where appropriate):
    
   1. The major or chief complaint(s) alleged as the reason for not working. The discussion of the complaints must include:
       
      1. A detailed historical description of the pertinent past history of the disease.
          
      2. The claimant's statement of current complaint.
          
   2. Current and past therapy for this disorder, and response to therapy, should be reported. Hospitalizations, surgical operations, and significant investigative procedures (e.g., myelography, CAT scan, MRI, Bone Scan) should be reported with the dates of the hospitalizations and result of the procedures.
       
   3. The symptoms alleged, including a description of:
       
      1. The character, location, and radiation of pain;
          
      2. Mechanical factors which incite and relieve the pain;
          
      3. Prescribed treatment, including name, dose, and frequency of any medications which are used;
          
      4. The claimant's typical daily activities; and
          
      5. Symptoms of weakness, other motor loss, or any sensory abnormalities.
          
   4. The use of drugs or alcohol.
       
   5. Other significant past illnesses, injuries, operations, particularly those involving the musculoskeletal system.
       
   6. From whom the history was obtained and an estimate of the reliability of the history.
       
2. Physical Examination -- The physical examination report should include a description and discussion (where appropriate) of:
    
   1. The claimant's general appearance and nutrition, any apparent skeletal or other musculoskeletal abnormalities.
       
   2. The orthopedic and neurological findings. These should include a description of:
       
      1. Muscle spasms, limitation of movement of the spine given quantitatively in degrees from the vertical position when there is significant limitation in motion, straight leg raising given quantitatively in degrees from the supine position and from the sitting position, motor and sensory abnormalities, and deep tendon reflexes. Deep tendon reflexes should be described as to intensity and symmetry.
          
      2. If there is no abnormality of range of motion of any affected joint on gross examination, that fact, rather than the actual degree of motion, may be reported.
          
      3. Motor function quantitated. The method of quantitation must be reported. The most widely used method involves recording from 0 to 5 as a fraction with the numerator representing the claimant's performance and the denominator representing a normal performance (e.g., 3/5).
          
      4. To what degree motor function is inhibited by spasticity, rigidity or pain.
          
      5. The specific distribution of sensory deficit or pain.
          
   3.  Muscle bulk. When there is asymmetry, specific measurement must be reported.
       
      1. Atrophy must be reported in terms of circumferential measurements of both thighs and lower legs (or upper or lower arms) at a stated point above and below the knee or elbow given in inches or centimeters.
          
      2. A specific description of atrophy of hand muscles may be given without measurements of atrophy but should include measurements of grip strength.
          
   4. Gait and station, including the claimant's ability to:
       
      1. Tandem walk;
          
      2. Walk on heels and toes;
          
      3. Hop;
          
      4. Bend;
          
      5. Squat;
          
      6. Arise from a squatting position;
          
      7. Dress and undress;
          
      8. Get up from a chair;
          
      9. Get on the examining table; and
          
      10. Cooperate during the examination.
           
3. Laboratory Tests -- X-rays or other laboratory tests
    
   1. The physician providing the formal interpretation must be identified.
       
   2. If the interpretation is provided on a separate report form, that report should be attached.
       
4. Findings
   
   The medical source's examination findings must be determined on the basis of the medical source's observations during the examination. (Alternative testing methods should be used to verify the objectivity of the abnormal findings, when possible; e.g., a seated straight-leg raising test in addition to a supine straight-leg raising test.)

Go to Listing of Impairments - Adults: Musculoskeletal System 1.00 for more information.

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Respiratory

In addition to the requirements for a general internal medical examination, the specific information listed below should be stated in a report of an examination in which the primary complaint is a respiratory disorder.

1. General Examination
    
   1. The report should note and describe:
       
      1. The occurrence of cough, labored breathing, use of accessory muscles of respiration, audible wheezing, pallor, cyanosis, hoarseness, clubbing of fingers, or the presence of chest wall deformity. Respiratory rate should be observed and reported.
          
      2. The diameter of the chest on inspiration and expiration, distention of neck veins and ankle edema.
          
      3. Whether the expiratory phase of respiration is prolonged.
          
      4. Breath sounds.
          
      5. Diaphragmatic motion.
          
      6. Presence or absence of adventitious sounds on auscultation of the chest.
          
   2. The employment history, when relevant to the disease, should be reported (e.g., pneumoconiosis or exposure to physical irritants producing respiratory symptoms.)
       
2. Dyspnea
    
   1. Characteristics -- Dyspnea should be described with respect to:
       
      1. Dates and mode of onset;
          
      2. Seasonal influence;
          
      3. Influence of infection and precipitating activities;
          
      4. Whether it is associated with palpitation, wheezing, chest discomfort, or hyperventilation symptoms.
          
   2. Respiratory Versus Cardiac Dyspnea -- Inquiry should be made to determine whether the claimant has:
       
      1. A history of heart disease;
          
      2. Experienced paroxysmal nocturnal dyspnea or orthopnea; and
          
      3. Associated peripheral edema, hypertension, past myocardial infarction, angina, rheumatic heart disease, cardiac murmur, etc.
          
3. Episodic Disorders -- The report should include details as to:
    
   1. Onset and precipitating factors;
       
   2. Frequency and intensity;
       
   3. Duration;
       
   4. Mode of treatment and response; and
       
   5. Description of severe respiratory attack.
       
4. Ancillary Studies
   
   Chest X-ray, Spirometry, Diffusing Capacity of the lungs for Carbon Monoxide, and Arterial Blood Gas Studies will be requested in accordance with program criteria for the purpose of establishing the existence and extent of the disease process.

Go to Listing of Impairments -Adults: Respiratory System 3.00 for more information.

Cardiovascular

In addition to the requirements for a general internal medical examination, the following specific information should be stated in a report of an examination in which the primary complaint is a cardiovascular disorder.

1. General Examination -- The report must:
    
   1. Provide a detailed description of the examination of the heart, including the heart sounds and rhythm and pulses.
       
   2. Describe:
       
      1. Any jugular vein distention, including angle of reclining at which distention occurs;
          
      2. Adventitious lung sounds;
          
      3. Hepatomegaly;
          
      4. Peripheral or pulmonary edema; and
          
      5. Cyanosis.
          
   3. Describe the impact of the chest discomfort, dyspnea or other cardiovascular symptoms on physical activities.
       
   4. Describe any drugs used (currently and in the recent past) for treatment of the cardiovascular disorder and indicate the dosage and the response to these drugs.
       
   5. Note participation in a cardiac rehabilitation program (e.g., progressive physical activity, educational or psychological support).
       
2. Congestive Heart Failure -- The history must include a discussion of:
    
   1. The known factors in the development of the cardiac condition (e.g., myocardial infarction, rheumatic heart disease, hypertension, and congenital or other organic heart disease).
       
   2. Recurrent or persistent symptoms such as:
       
      1. Fatigue;
          
      2. Dyspnea;
          
      3. Orthopnea; and
          
      4. Anginal discomfort.
          
3. Chest Discomfort and Other Symptoms -- The report should describe:
    
   1. Chest discomfort of myocardial ischemic origin or other symptom(s) in the claimant's own words with respect to:
       
      1. Presence;
          
      2. Character;
          
      3. Location;
          
      4. Radiation;
          
      5. Frequency;
          
      6. Duration;
          
      7. Usual inciting factors; and
          
      8. Relief.
          
   2. The historical character of the chest discomfort to ascertain whether:
       
      1. There is a predictable stable pattern of occurrence; and
          
      2. There is evidence of a recent change in the pattern of symptoms.
          
   3. Whether therapy has been prescribed and how the claimant is responding to the therapy;
       
   4. Whether the discomfort occurs at rest or awakens the claimant from sleep and whether it is related to ingestion of food or movement of the upper extremities; and
       
   5. The usual duration of the symptoms, especially chest discomfort, how symptoms are relieved, and the time required to obtain relief (e.g., rest or after taking specific drugs such as nitroglycerin).
       
4. Laboratory Tests

   Ancillary cardiac testing, such as ECG, Exercise Stress Testing and Echocardiogram, will be requested in accordance with program criteria for the purpose of establishing the existence and extent of the disease process.

Go to Listing of Impairments - Adults: Cardiovascular System 4.00 for more information.
 

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Neurological

1. Historical Source
    
   1. The DDS will make arrangements to have a knowledgeable individual accompany the claimant to the examination, when prior information indicates incompetence on the part of the claimant.
       
   2. The medical source should indicate from whom the history was obtained and should estimate reliability of history.
       
2. History -- The history should include a detailed description/discussion of:
    
   1. Major or chief complaints with:
       
      1. Detailed historical description of the disease state; and
          
      2. Current complaints.
          
   2. The mental or physical functional restrictions with specific examples.
       
   3. Significant illness, injuries, or operations, particularly of the nervous system.
       
   4. Current and past therapy for the disorder alleged, and any abuse or drugs or alcohol.
       
   5. The family history with information on pertinent positive abnormalities, particularly hereditary familial conditions.
       
3. Physical Examination
    
   1. General -- The physical examination should provide a statement concerning the claimant's:
       
      1. General appearance;
          
      2. Nutrition;
          
      3. Body habitus;
          
      4. Head size and shape;
          
      5. Any skeletal or other abnormalities such as pigmentary or texture changes of the skin or changes in hair distribution; and
          
      6. Dominant hand
          
   2. The gait and station must be described in detail, including ability to:
       
      1. Tandem walk;
          
      2. Walk on heels and toes;
          
      3. Hop;
          
      4. Dress and undress;
          
      5. Get up from a chair;
          
      6. Get on the examining table; and
          
      7. Generally cooperate during the examination.
          
   3. Notation should be made of the function of the 12 cranial nerves (if the first cranial nerve is not tested, this should be noted). Lower cranial nerve function should be described in particular detail when dysphagia or dysarthria is a complaint.
       
   4. Ocular motility and pupillary size and activity should be described even when normal. The visual acuity and visual fields by gross confrontation should be estimated, and the basis for the estimate must be stated.
       
   5. Motor function -- Should be quantitated, and the method of quantitation reported. For example, if a numbering system is used, the report must state which number represents normal strength and which number represents total paralysis.
       
      1. The report must also describe to what degree motor function is inhibited by spasticity, rigidity, involuntary movements, or tremor.
          
      2. Muscle bulk should be described, and when there is asymmetry, measurements should be reported.
          
      3. The degree of fatigability following rapid, repetitive movements should be noted.
          
   6. All modalities of sensation, including cortical, should be tested.
       
      1. The method of testing should be recorded.
          
      2. When sensory deficit or pain are described in a specific distribution, care should be taken to ascertain that the findings are consistent with neuroanatomical fact. Suspected non-physiological observations should be noted.
          
   7. Coordination should be tested.
       
      1. The ability to perform fine and dexterous movements of the hands should be described.
          
      2. In-coordination or tremor at rest or during specific tests should be described in detail and quantitated.
         
         NOTE: Examples should be given describing the functional loss that occurs because of these events.
          
   8. Reflexes
       
      1. Deep tendon reflexes should be described as to intensity and symmetry.
          
      2. Superficial reflexes should be described when present and noted when absent.
          
      3. Any pathological reflexes must be described in detail.
          
   9. Any impairment of speech or language should be described in detail with a discussion of how much ability the claimant retains and how the medical source determined this. The report should discuss:
       
      1. Aphasia;
          
      2. Dysarthria;
          
      3. Stuttering (fluency);
          
      4. Involuntary vocalizations;
          
      5. Whether speech is intelligible.
          
4. Mental Status Examination -- should be reported and be extensive when mental capacity is in question. The physician should provide:
    
   1. Examples of responses in testing orientation, memory, calculation, insight, general understanding, and fund of knowledge; and
       
   2. A detailed description of mood and behavior during the examination, and any significant abnormalities.

Go to Listing of Impairments - Adult: Neurological 11.00 for more information.
 

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Mental Disorders

The psychiatric or psychological examination report should show not only the claimant's signs, symptoms, laboratory findings (psychological test results), and diagnosis, but also describe the effect of the emotional or mental disorder on the claimant's ability to function at the usual and customary level of adjustment -- personal, social and occupational.

1. General Observations -- Include in the CE report general observations of:
    
   1. How the claimant came to the examination:
       
      1. Alone or accompanied;
          
      2. Distance and mode of transportation; and
          
      3. If by automobile, who drove.
          
   2. General appearance:
       
      1. Dress; and
          
      2. Grooming
          
   3. Attitude and degree of cooperation.
       
   4. Posture and gait.
       
   5. General motor behavior, including any involuntary movements.
       
2. Informant

   The medical source should identify the person providing the history (usually the claimant) and should provide an estimate of the reliability of the history.
    

3. Chief Complaint
   
   This usually will consist of the claimant's allegations concerning any mental and/or physical problems.
    
4. History of Present Illness
   
   This should include a detailed chronological account of the onset and progression of the claimant's current mental/emotional condition with special reference to:
    
   1. Date and circumstances of onset of the condition;
       
   2. Date the claimant reported that the condition began to interfere with work, and how it interfered;
       
   3. Date the claimant reported inability to work because of the condition and the circumstances;
       
   4. Attempts to return to work and the results;
       
   5. Outpatient evaluations and treatment for mental/emotional problems including:
       
      1. Names of treating sources;
          
      2. Dates of treatment;
          
      3. Types of treatment (names and dosages of medications, if prescribed); and
          
      4. Response to treatment.
          
   6. Hospitalizations for mental disorders including:
       
      1. Names of hospitals;
          
      2. Dates; and
          
      3. Treatment and response.
          
   7. Information concerning the claimant's:
       
      1. Activities of daily living;
          
      2. Social functioning;
          
      3. Ability to complete tasks timely and appropriately; and
          
      4. Episodes of decompensation and their resulting effects.
          
5. Past History should include a longitudinal account of the claimant's personal life including:
    
   1. Relevant educational, medical, social, legal, military, marital, and occupational data and any associated problems in adjustment;
       
   2. Details (dates, places, etc.) of any past history of outpatient treatment and hospitalizations for mental/emotional problems; and
       
   3. History, if any, of substance abuse, and/or treatment in detoxification and rehabilitation centers.
       
6. Mental Status
   
   The individual case facts will determine the specific areas of mental status that need to be emphasized during the examination, but generally the report should include a detailed description of the claimant's:
    
   1. Appearance, behavior, and speech (if not already described);
       
   2. Thought process (e.g., loosening of associations);
       
   3. Thought content (e.g., delusions);
       
   4. Perceptual abnormalities (e.g., hallucinations);
       
   5. Mood and affect (e.g., depression, mania);
       
   6. Sensorium and cognition (e.g., orientation, recall, memory, concentration, fund of information, and intelligence);
       
   7. Judgment and insight; and
       
   8. Capability (i.e., is the individual capable of handling awarded benefits responsibly?)
       
7. Diagnosis
   
   American Psychiatric Association standard nomenclature as set forth in the current "Diagnostic and Statistical Manual of Mental Disorders."
    
8. Prognosis
   
   Prognosis and recommendations for treatment, if indicated; also, recommendations for any other medical evaluation (e.g., neurological, general physical), if indicated.

Additional Requirements by Mental Disorder

1. Schizophrenic, Delusional (Paranoid) Schizo-Affective, and other Psychotic Disorders -- The report should reflect:
    
   1. Periods of residence in structured settings such as half-way houses and group homes;
       
   2. Frequency and duration of episodes of illness and periods of remission; and
       
   3. Side effects of medications.
       
2. Organic Mental Disorders -- The report should reflect:
    
   1. The source of the disorder, if known, the prognosis; and
       
      1. Whether there is an acute or chronic process;
          
      2. Whether stable or progressive; and
          
      3. Changes at various points in time.
          
   2. The results of any psychological or neuropsychological testing that could serve to further document an organic process and its severity.
       
   3. Information regarding the results of any neurological evaluations.
       
   4. Information about any neurological testing (e.g., EEG, CT scan) that may have been performed and the results, if available.
       
3. In Mental Retardation cases, the report should reflect:
    
   1. Current documentation of IQ by a standardized, well-recognized measure. Acceptable instruments will have a representative normative sample, a mean of approximately 100 and standard deviation of approximately 15 in the general population, and cover a broad range of cognitive and perceptual-motor functions (e.g., the Wechsler scales);
       
   2. Verbal IQ, performance IQ, and full scale IQ scores, together with the individual subtest scores;
       
   3. Interpretation of the scores and assessment of the validity of the obtained scores, indicating any factors that may have influenced the results such as the claimant's attitude and degree of cooperation, the presence of visual, hearing or other physical problems, and recent prior exposure to the same or similar test; and
       
   4. Consistency of the obtained test results with the claimant's education, vocational background, and social adjustment, especially in the area of personal self-sufficiency.
      
      

   Go to Listing of Impairments- Adults: Mental Disorders 12.00 for more information.

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