DI 22510.047 Pediatric CE Report Content Guidelines - Neurological Disorders
A. Policy - General
Specific requirements exist in addition to all general pediatric guidelines in DI 22510.035.
B. Policy - Description for Seizures
If seizures are present, there should be a description of:
abnormal behavior prior to seizure;
Frequency, timing, provocative factors;
Nature and duration of seizure activity;
Duration of post-ictal state;
Medication with dosage (including any recent adjustments to medication);
Response to treatment; and
Side effects of medication;
Any signs of injury due to seizures;
Episodes of headache;
Speech and language abnormalities;
Abnormal movements and coordination.
C. Policy - Physical Exam
The physical exam should include a description of the claimant's:
Mental status (e.g., orientation);
Reflexes, balance, strength;
Fine motor skills; and,
Gait (where age-appropriate) at rest and with activity.
Coordination and abnormal movements, if any.
NOTE: When formal muscle strength testing is not possible for younger children, record observations of sitting, pulling, rolling over, rising from supine position, etc.