BASIC (04-00)

DI 22510.022 CE Report Content Guidelines - Internal Medicine

A. Policy -General Format and Detail

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

B. Policy - Content

1. Source Of History

The physician 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:

    • Factors which increase the problem or impairment(s);

    • How long the problem has been present;

    • Factors which may provide relief; and

    • 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” form.

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

Pertinent findings about use of tobacco products, alcohol, nonprescription drugs, etc. should be presented.

7. Family History

Should be presented, if pertinent.

8. Signs

  1. The vital signs should include:

    • Blood pressure;

    • Pulse rate;

    • Respiratory rate; and

    • 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).

    • This description must be in narrative, rather than “questionnaire” or “check-off” form.

    • 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

  1. The laboratory should provide:

    • Actual values for laboratory tests; and

    • Normal ranges of values in either the medical report or attached laboratory report.

  2. Electrocardiographic and Spirographic Reports

    • Tracings must be provided when these tests have been performed. The reported findings for ventilatory and electrocardiographic studies must meet the requirements of section 3.00E and 4.00C, respectively, of the Listing of Impairments.

  3. Interpretation

    • The interpretation of laboratory tests (e.g., electrocardiographic tracings) must take into account and be
      correlated with the history and physical examination
      findings.

    • When imaging studies or other laboratory tests are performed, the medical source performing and interpreting the test must be identified. The test report and interpretation should be attached, if provided separately.

  4. X-rays

    Joints to be x-rayed are those