TN 4 (09-04)
DI 22510.021 Consultative Examination (CE) Report Content Guidelines - Mental Disorders
A. Policy - General
The CE report for mental disorders should show the individual's signs, symptoms, laboratory findings (for example, psychological test results), and diagnosis, as well as the effect of the mental disorder on the individual's ability to function in personal, social, and occupational situations.
For CE report content guidelines for mental disorders in children, see DI 22510.048.
B. Policy - General Requirements
1. General Observations
The CE report should include general observations of:
How the individual came to the examination
Attitude and degree of cooperation.
Posture and gait.
The consultative examiner 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 individual's allegations concerning any mental or physical problems.
4. History of Present Illness
This should include a detailed chronological account of the onset and progression of the individual's current mental/emotional condition with special reference to:
Date and circumstances of onset of the condition.
Date the individual reported that the condition began to interfere with work, and how it interfered.
Date the individual reported inability to work because of the condition, and the circumstances.
Attempts to return to work and the results.
Outpatient evaluations and treatment for mental and emotional problems, including:
Hospitalizations for mental disorders, including:
Names of hospitals;
Treatment and response.
Information concerning the individual's:
Activities of daily living;
Ability to complete tasks timely and appropriately; and
Episodes of decompensation and their resulting effects.
5. Past History
This should include a longitudinal account of the individual's personal life, including:
Relevant educational, medical, social, legal, military, marital, and occupational data and any associated problems in adjustment;
Details (dates, places, etc.) of any past history of outpatient treatment and hospitalizations for mental/emotional problems; and
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 individual's:
Appearance, behavior, and speech (if not already described);
Thought process (for example, loosening of associations);
Thought content (for example, delusions);
Perceptual abnormalities (for example, hallucinations);
Mood and affect (for example, depression, mania);
Sensorium and cognition (for example, orientation, recall, memory, concentration, fund of information, and intelligence); and,
Judgment and insight.
This should include the American Psychiatric Association standard nomenclature as set forth in the current “Diagnostic and Statistical Manual of Mental Disorders.”
Prognosis and recommendations for treatment, if indicated, should be provided. Recommendations for any other medical evaluation (for example, neurological, general physical), if indicated, should also be given.
9. Capability Development
Develop capability in every case (initial, reconsideration, continuing disability review) when a CE for a mental disorder is being purchased (see DI 23001.010B.1.).
C. Policy - Additional Requirements by Impairment
1. Schizophrenic, Delusional (Paranoid), Schizoaffective, and Other Psychotic Disorders
The report should reflect:
Periods of residence in structured settings such as half-way houses and group homes;
Frequency and duration of episodes of illness and periods of remission; and
Side effects of medications.
2. Organic Mental Disorders
The report should reflect:
The source of the disorder, if known, the prognosis, and
Whether there is an acute or chronic process;
Whether stable or progressive; and
Changes at various points in time.
The results of any psychological or neuropsychological testing that may have been performed that could serve to further document an organic process and its severity.
Information regarding the results of any neurological evaluations.
Information about any neurological testing (for example, EEG, CT scan) that may have been performed and the results, if available.
3. Intellectual Disability
The report should reflect:
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 (for example, the Wechsler scales);
Summary of composite scores (for example, Full Scale IQ, Verbal Comprehension Index, Perceptual Reasoning Index) together with the individual subtest scores;
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 individual'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
Consistency of the obtained test results with the individual's education, vocational background, and social adjustment, especially in the area of personal self-sufficiency.