DI 22510.026 CE Report Content Guidelines - Neurological Disorders
A. Policy - General
Specific requirements exist in addition to all general internal medicine guidelines. See DI 22510.022.
B. Policy - Specific
1. Background Medical Information
MER is necessary to evaluate neurological disorders, since the longitudinal findings are particularly critical to assessing severity and duration.
In cases of alleged epilepsy, it is particularly important to obtain MER from the treating source.
2. Historical Source
Arrangements should be made to have a knowledgeable individual accompany the claimant to the examination, when prior information indicates incompetency on the part of the claimant.
The physician should indicate from whom the history was obtained and should estimate reliability of history.
The history should include a detailed description/discussion of:
Major or chief complaints with:
The mental or physical functional restrictions with specific examples.
Significant illness, injuries, or operations, particularly of the nervous system.
Current and past therapy for the disorder alleged, and any abuse of drugs or alcohol.
The family history with information on pertinent positive abnormalities, particularly hereditary familial conditions.
4. Physical Examination
General -The physical examination should provide a statement concerning the claimant's:
The gait and station must be described in detail, including ability to:
Notation should be made of the function of the 12 cranial nerves (if the first cranial nerve is not tested, this should be noted). Lower cranial nerve function should be described in particular detail when dysphagia or dysarthria is a complaint.
Ocular motility and pupillary size and activity should be described even when normal. The visual acuity and visual fields by gross confrontation should be estimated, and the basis for the estimate must be stated.
Motor function - Should be quantitated, and the method of quantitation reported. For example, if a numbering system is used, the report must state which number represents normal strength and which number represents total paralysis.
The report must also describe to what degree motor function is inhibited by spasticity, rigidity, involuntary movements, or tremor.
Muscle bulk should be described, and when there is asymmetry, measurements should be reported.
The degree of fatigability following rapid, repetitive movements should be noted.
All modalities of sensation, including cortical should be tested.
The method of testing should be recorded.
When sensory deficit or pain are described in a specific distribution, care should be taken to ascertain that the findings are consistent with neuroanatomical fact. Suspected nonphysiological observations should be noted.
Coordination - should be tested.
The ability to perform fine and dexterous movements of the hands should be described.
Incoordination or tremor at rest or during specific tests should be described in detail and quantitated.
NOTE: Examples should be given describing the functional loss which occurs because of these events.
Deep tendon reflexes should be described as to intensity and symmetry.
Superficial reflexes should be described when present and noted when absent.
Any pathological reflexes must be described in detail.
Any impairment of speech should be described in detail with a discussion of how much ability the claimant retains and how the physician determined this. The report should discuss:
5. Mental Status Examination
Should be reported, and be extensive when mental capacity is in question. The physician should provide:
Examples of responses in testing orientation, memory, calculation, insight, general understanding, and fund of knowledge; and
A detailed description of mood and behavior during the examination, and any significant abnormalities.