TN 23 (09-20)

DI 22510.050 Pediatric Consultative Examination (CE) Report Content Guidelines for Immune System Disorders

Use the following guidelines to provide the minimum content in a CE report for a child disability case. Each Disability Determination Service (DDS) will notify medical sources of any additional requirements.

A. General guidelines for CE report content for pediatric immune system disorders

The CE report content guidelines in this section are in addition to the general pediatric CE report content guidelines in DI 22510.035. For additional CE policy in a child's case, also see DI 25205.015.

B. Report content specific to pediatric immune system disorders

The CE provider will use the specific requirements below to complete the CE report for an immune system disorder.

1. Current medical history

The CE provider will describe and discuss, as appropriate:

  1. a. 

    Weight loss;

  2. b. 

    Fever;

  3. c. 

    Pain;

  4. d. 

    Fatigue;

  5. e. 

    Malaise;

  6. f. 

    Type, frequency, and severity of any infections, especially systemic infections – sepsis, meningitis, endocarditis, osteomyelitis;

  7. g. 

    Stem cell transplantation and any adverse effects; and

  8. h. 

    Difficult to control dermatologic conditions.

2. Physical examination

The CE provider will describe and discuss, as appropriate:

  1. a. 

    Signs of affected body systems, such as heart, lungs, kidneys, eyes, digestive system, skin, etc.;

  2. b. 

    Temperature;

  3. c. 

    Joint pain, swelling, tenderness, contractures, deformities;

  4. d. 

    Muscle weakness, atrophy, pain;

  5. e. 

    Skin abnormalities; and

  6. f. 

    Extra-articular findings.

 


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0422510050
DI 22510.050 - Pediatric Consultative Examination (CE) Report Content Guidelines for Immune System Disorders - 01/23/1996
Batch run: 09/25/2020
Rev:01/23/1996