Effective Dates: 09/01/2005 - Present Previous | Next

TN 23 (09-20)

DI 22510.042 Pediatric Consultative Examination (CE) Report Content Guidelines for Genitourinary 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 genitourinary 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 genitourinary disorders

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

1. Current medical history

The CE provider will describe and discuss, as appropriate:

  1. a. 

    Malaise;

  2. b. 

    Fatigue;

  3. c. 

    Poor appetite;

  4. d. 

    Edema;

  5. e. 

    Headaches;

  6. f. 

    Bone pain;

  7. g. 

    Urinary frequency, dysuria, hematuria, and/or incontinence;

  8. h. 

    Renal ultrasound results;

  9. i. 

    Type and frequency of urological procedures; and

  10. j. 

    Acute weight gain or loss.

2. Physical examination

The CE provider will describe and discuss, as appropriate:

  1. a. 

    Pallor;

  2. b. 

    Fundoscopic and any retinal change;

  3. c. 

    Edema – type and location;

  4. d. 

    Anasarca;

  5. e. 

    Congenital abnormalities; and

  6. f. 

    Neurological findings – irritability and hypotonia.

To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0422510042
DI 22510.042 - Pediatric Consultative Examination (CE) Report Content Guidelines for Genitourinary Disorders - 09/01/2005
Batch run: 09/25/2020
Rev:09/01/2005