TN 3 (04-03)

DI 22510.023 Consultative Examination Report Content Guidelines - Inflammatory Arthritis

A. Policy - General

Specific requirements exist in addition to all general internal medicine guidelines. See DI 22510.022.

B. Policy - Specific

1. General Observations

General observations in the physical examination should relate to common, everyday functions that may be observed in the consultative examiner's office, such as:

a. Position

Station or posture.

b. Gait

Ability to ambulate both with and without assistive devices, unless contraindicated by the medical judgment of a physician who has treated or examined the individual, and with orthoses and prosthetics in place, where appropriate, without causing injury to the individual. If the individual has difficulty with or is unable to use, the orthotic or prosthetic device, the medical basis for the difficulty should be documented. In addition, in such cases, if the impairment involves a lower extremity or extremities, the examination should include information on the individual's ability to ambulate effectively without the device in place, unless contraindicated by the judgment of a physician who has treated or examined the individual. Furthermore, the individual's medical ability to use a prosthesis to ambulate effectively should also be evaluated.

c. Ability

Ability to:

  • Tandem walk;

  • Walk on heels and toes;

  • Bend;

  • Squat;

  • Arise from a squatting position;

  • Dress and undress;

  • Get up from a chair;

  • Get on and off the examining table;

  • Grasp or shake hands;

  • Write;

  • Button and unbutton clothes, use zippers, grip, and turn door handles; and

  • Cooperate during the examination.

2. Joint Examination

a. Joint Examination

Joint examination should include specific, detailed notations with respect to the presence or absence of:

  • Effusion;

  • Periarticular swelling;

  • Tenderness;

  • Heat;

  • Redness;

  • Thickening of the joints;

  • Specific range of motion of the joints, and of the neck and thoracolumbar spine given quantitatively in degrees from the vertical position (zero degrees); and

  • Structural deformities.

b. Range of Motion of Joints and Spine Must Be Measured

The range of motion of joints and spine must be measured according to the requirements in section 1.00G. of the Listing of Impairments.

c. Range of Motion is Restricted in Any Joint or the Spine

If the range of motion is restricted in any joint or the spine, annotate the probable cause (for example, due to an observable abnormality or due to pain.).

d. Joint and Spine X-rays or Other Appropriate Medically Acceptable Imaging

Joint and spine x-rays or other appropriate medically acceptable imaging should be obtained, where appropriate, after a thorough musculoskeletal examination. Some tests, such as CAT scans and MRIs, are quite expensive, and we will not routinely purchase them.

3. Symptoms and Signs

The presence of constitutional symptoms (for example, fatigue, malaise) and signs (for example, fever, weight loss) should be recorded.

4. Other Organs or Body Systems

The involvement of other organs or body systems should be recorded.


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0422510023
DI 22510.023 - Consultative Examination Report Content Guidelines - Inflammatory Arthritis - 07/09/2012
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