TN 23 (09-20)

DI 22510.044 Pediatric Consultative Examination (CE) Report Content Guidelines for Skin 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 skin 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 skin disorders

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

1. Current medical history

The CE provider will describe and discuss, as appropriate:

a. Dates of relevant diagnostic procedures such as biopsy and genetic testing;

b. Results of relevant diagnostic procedures;

c. Treatment modalities, dates of treatments, and responses to treatments; and

d. Effects on age-appropriate activity, especially social behavior, because of disfigurement.

2. Physical examination

The CE provider will describe and discuss, as appropriate:

  1. a. 

    Contractures or type of lesion and extent of the body affected. Include a specific description of any involvement of the palmar and/or plantar surfaces. If present, the effect on hand use and ambulation should be noted;

  2. b. 

    Duration of skin lesion(s):

  3. c. 

    Joint functioning including range of motion of the affected joint(s); and

  4. d. 

    Optional with consent of the claimant/guardian: a digital photograph to document the severity of the skin lesion(s).


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0422510044
DI 22510.044 - Pediatric Consultative Examination (CE) Report Content Guidelines for Skin Disorders - 10/05/2004
Batch run: 09/25/2020
Rev:10/05/2004