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.