TN 35 (10-23)

DI 22510.041 Pediatric Consultative Examination (CE) Report Content Guidelines for Digestive Disorders

Use the following guidelines to provide the minimum content in a CE report for a child disability case. Each Disability Determination Service (DDS) will notify medical sources of any additional requirements.

A. General guidelines for CE report content for pediatric digestive disorders

The CE report content guidelines in this section are in addition to the general pediatric CE report content guidelines in DI 22510.035. For additional CE policy in a child’s case, also see DI 25205.015.

B. Report content specific to pediatric digestive disorders

The CE provider will use the specific requirements below to complete the CE report for a digestive disorder.

1. Current medical history

The CE provider will describe and discuss, as appropriate:

  1. a. 

    Fatigue, muscle weakness, sensory abnormalities, cognitive impairment, malaise, and/or loss of appetite;

  2. b. 

    Sleep disturbance and any other nocturnal symptoms;

  3. c. 

    Pain, if present, and its location;

  4. d. 

    Eating habits, and unusual weight loss or gain;

  5. e. 

    Bowel and bladder patterns;

  6. f. 

    Rectal bleeding, if the claimant allows the physician to observe the rectum;

  7. g. 

    Nausea;

  8. h. 

    Growth failure; and

  9. i. 

    Dates and results of relevant diagnostic procedures (such as diagnostic imaging, endoscopy, biopsy, aspiration of ascetic fluid, and clinical laboratory test).

2. Physical examination.

The CE provider will describe and discuss, as appropriate:

  1. a. 

    Length, height, and weight;

  2. b. 

    Nutritional status;

  3. c. 

    Presence of jaundice and pallor;

  4. d. 

    Liver and spleen size;

  5. e. 

    Muscle wasting;

  6. f. 

    Presence of edema, ascites, and asterixis;

  7. g. 

    Presence of any abdominal masses; and

  8. h. 

    Evidence of perianal disease.

3. Laboratory tests or findings

The CE provider will describe and discuss, as appropriate. Laboratory testing should include, if appropriate:

  1. a. 

    Serum creatinine;

  2. b. 

    Serum total bilirubin;

  3. c. 

    International normalized ratio (INR);

  4. d. 

    Serum albumin; and

  5. e. 

    Hemoglobin.

 


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0422510041
DI 22510.041 - Pediatric Consultative Examination (CE) Report Content Guidelines for Digestive Disorders - 10/06/2023
Batch run: 02/13/2024
Rev:10/06/2023