TN 3 (04-03)
DI 22510.027 Consultative Examination Report Content Guidelines - Musculoskeletal
A. Policy - General
Specific requirements exist in addition to all general internal medicine guidelines. See DI 22510.022.
B. Policy - Specific
The report of the musculoskeletal examination, including the lumbar and cervical spine, should describe and discuss (where appropriate):
a. Major or Chief Complaint(s) Alleged as Reason for Not Working
The discussion of the complaints must include a detailed description of the pertinent past history of the alleged musculoskeletal problems.
b. Current and Past Treatment for Disorder and Response to Treatment
Dates and reasons for hospitalizations, surgeries, and significant diagnostic procedures (for example, myelography, CAT scan, MRI, radionuclear bone scans) should be reported with the results of any procedures described.
c. Symptoms Alleged
The symptoms alleged, including a description of:
The character, location, and radiation of pain;
Mechanical factors that incite and relieve the pain;
Prescribed treatment, including name, dose, and frequency of any medications that are used; and any reported side effects of medication;
The individual's typical daily activities; and
Symptoms of weakness, other motor loss, or any sensory abnormalities.
d. Drugs or Alcohol
The use of drugs or alcohol.
e. Other Significant Past or Present Illnesses, Injuries and Operations
Other significant past or present illnesses, injuries, and operations, particularly those involving the musculoskeletal system.
From whom the history was obtained and an estimate of the reliability of the history.
2. Physical Examination
The physical examination report should include a description and discussion (where appropriate) of:
a. Appearance and Nutrition
The individual's general appearance and nutrition and any apparent gross skeletal or other musculoskeletal abnormalities.
b. Musculoskeletal and Neurological Findings
The musculoskeletal and neurological findings. These should include a description of:
Muscle spasms (when present), range of motion of the neck and spine given quantitatively in degrees from the vertical position (zero degrees), straight leg raising given quantitatively in degrees from the supine position and from the sitting position, or any other appropriate tension signs, motor and sensory abnormalities, and deep tendon reflexes. Deep tendon reflexes should be described as to intensity and symmetry.
Range of motion of joints and the neck and spine measured according to the requirements in section 1.00G. of the Listing of Impairments. If there is no abnormality of range of motion of any affected joint on gross examination, that fact may be reported rather than the actual degree of motion.
Joint deformity, instability, or swelling.
Motor function quantitated. The most widely used method of strength measurement involves recording from 0 to 5 as a fraction with the numerator representing the individual's performance and the denominator representing a normal performance (for example, 3/5).
The degree to which motor function is inhibited by spasticity, rigidity, or pain.
The specific distribution of sensory deficit or pain.
If there has been an amputation, a description of the condition of the stump and of any stump complications.
c. Muscle Bulk
When there is asymmetry, specific measurement must be reported and:
A report of atrophy should be accompanied by measurement of strength.
Atrophy must be reported in terms of circumferential measurements of both thighs and lower legs (or upper or lower arms) at a stated point above and below the knee or elbow given in inches or centimeters.
A specific description of atrophy of hand muscles may be given without measurements of atrophy, but should include measurements of grip and pinch strength and ability to perform fine and gross manipulations.
d. Gait and Station
Gait and station, including the individual's ability to:
Ambulate both with and without assistive devices, 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.
Walk on heels and toes;
Arise from a squatting position;
Dress and undress;
Get up from a chair;
Get on and off the examining table;
Grasp or shake hands;
Button and unbutton clothes, use zippers, grip, and turn door handles; and
Cooperate during the examination.
3. Laboratory Tests
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.
The medical source's examination findings must be determined on the basis of the medical source's observations during the examination. (Alternative testing methods should be used to verify the objectivity of the abnormal findings, when possible; for example, a seated straight-leg raising test in addition to a supine straight-leg raising test).