TN 22 (09-20)

DI 22510.112 Adult Consultative Examination (CE) Report Content Guidelines for Mental Disorders

Use the following guidelines to provide minimum content for CE reports for adult claimants with mental disorders. Each Disability Determinations Service (DDS) will notify medical sources of any additional requirements.

A. General guidelines for CE report content for adult mental disorders

The CE report guidelines for adult mental disorders in this section are in addition to the general CE report content guidelines in DI 22510.100.

B. Identification

1. The CE provider will include the claimant’s name, date of birth, and/or claim number; and

2. The CE provider will indicate that the claimant provided proof of identity by showing a valid and current government photo identification (for example, U.S. State-issued driver’s license, U.S. State-issued non-driver identity card, U.S. passport, U.S. military ID, or Student or school ID, etc.), or provide a physical description of the claimant to verify that the person being examined is the claimant, except if the claimant's medical source with a treating relationship is the CE provider.

C. Medical history

1. Longitudinal medical history

a. The CE provider will cite and describe the medical records and any other documents reviewed during the course of the evaluation;

b. The CE provider will identify the person(s) providing the oral medical history and an assessment of the validity and reliability of such information; and

c. If the person providing the oral medical history is someone other than the claimant, the CE provider will indicate whether the person was interviewed separately or in the presence of the claimant.

2. Current medical history

a. The primary impairment(s) alleged as the reason for not working. This information must be in a narrative, rather than a “questionnaire” or “check-off” form, and pertinent descriptive statements by the claimant, should be recorded in the claimant’s own words. This description must include:

1. History of the onset and progress of the disorder;

2. The claimant’s statement of current symptom(s);

3. Type and resultant effect of any treatment;

4. Factors which increase the problem or impairment or that may provide relief; and

5. The claimant’s typical daily activities and the claimant’s description of how their disorder(s) and or impairment(s) limit their ability to function.

b. Information provided by the claimant, or other source. This report should provide a detailed description of the claimant’s:

1. Ability to understand, remember, and apply information;

2. Ability to interact with others;

3. Ability to concentrate, persist, and maintain pace;

4. Ability to adapt and manage oneself;

5. Ability to function in personal, social, and occupational situations;

6. Attempts to return to work and the results; and

7. Daily activities.

3. Past medical history

a. Outpatient evaluations and treatment for mental and emotional problems, including:

1. Names of medical sources providing treatment;

2. Dates of treatment;

3. Types of treatment (names and dosages of medications, if prescribed); and

4. Response to treatment.

b. Hospitalization for the disorder, including:

1. Names of hospitals;

2. Dates; and

3. Treatment and response.

4. Current medications

The CE provider will list the name, dose, and frequency of medication(s), including both beneficial and adverse effects, and plans for continued drug administration, schedule, and extent of any therapy.

D. Longitudinal account of the claimant's personal life

The CE provider will describe and discuss, as appropriate:

1. Relevant educational, medical, social, legal, military, marital, and occupational data; and any associated problems in adjustment;

2. Details (dates, places, etc.) of any past history of outpatient treatment and hospitalizations for mental/emotional conditions; and

3. History, if any, of substance use or treatment in detoxification and rehabilitation centers.

E. Mental status examination

The CE provider will describe and discuss, as appropriate:

a. Appearance, behavior, and speech (if not already described). For example, dress, grooming, and appearance of invalidism;

b. Thought process. For example, loosening of associations;

c. Thought content. For example, delusions;

d. Perceptual abnormalities. For example, hallucinations;

e. Mood and affect. For example, depression or mania;

f. Sensorium and cognition. For example, orientation, concentration, remote memory, recall of new information, fund of information, and estimated intelligence;

g. Judgment and insight;

NOTE: The description of the claimant’s mental status must not be an enumeration of the symptoms reported by the claimant (or other source) in DI 22510.112 B.2., rather the description must be the examining source’s description of the above items.

h. Further, the CE provider will describe and discuss general observations, as appropriate;

i. How the claimant came to the examination;

1. Alone or accompanied;

2. Distance and mode of transportation; and

3. If by automobile, who drove.

j. Attitude and degree of cooperation;

k. Posture and gait; and

l. Involuntary movements.

F. Diagnosis

The report should include the American Psychiatric Association standard nomenclature as set forth in the current edition of the Diagnostic and Statistical Manual of Mental Disorders.

G. Prognosis

The CE report should include prognosis and recommendations for treatment, if indicated. The report should also include recommendations for any other medical evaluation (for example, neurological, general physical), if indicated.

H. Capability

The report should include information about whether the claimant can manage his or her funds.

I. Additional requirements for specific mental disorders

1. Schizophrenia spectrum and other psychotic disorders

If the claimant has alleged a disorder on the schizophrenia spectrum or other psychotic disorders the medical source must provide a detailed description of the following, as appropriate:

a. Periods of residence in structured settings such as half-way houses and group homes;

b. Frequency and duration of episodes of illness and periods of remission; and

c. Side effects of medications.

2. Neurocognitive disorders

If the claimant has alleged a neurocognitive disorder, the medical source must provide a detailed description of the following, as appropriate:

a. The etiology of the disorder and onset date (if known), the prognosis, and:

1. Whether there is an acute or chronic process;

2. Whether stable or progressive;

3. Changes at various points in time; and

4. Whether there has been a clinically significant decline in cognitive functioning and, if so, the basis for the conclusion that there has been a decline.

b. The results of any psychological or neuropsychological testing that may have been performed that could serve to further document an organic process and its severity.

c. Information regarding the results of any neurological evaluations.

3. Intellectual disability

The report of intellectual disability should include the following:

a. Current documentation of IQ by a standardized test of general intelligence; Acceptable test instruments (for example, the Wechsler scales) are those that:

1. Meet contemporary psychometric standards for validity, reliability, normative data, and scope of measurement;

2. Are individually administered according to all pre-requisite testing conditions; and

3. Have a mean of 100 and a standard deviation of 15.

b. Summary of composite scores;

For example, Full Scale IQ, Verbal Comprehension Index, Perceptual Reasoning Index) together with the individual subtest scores.

c. Interpretation of the obtained scores;

The medical source should indicate whether the scores are representative of the claimant’s present level of intellectual functioning.

d. Any factors that may have influenced the results, such as the claimant’s attitude and degree of cooperation, the presence of visual, hearing, or other physical problems, and recent prior exposure to the same or similar test; and

e. Consistency of the obtained test results with the claimant’s education, vocational background, and social adjustment, especially in the area of personal self-sufficiency.

J. Provide a medical opinion

a. The CE provider will specify the nature and extent of the condition(s) or disorder(s);

b. The CE provider will discuss any apparent discrepancies in the medical history or in the examination findings;

c. The CE provider will specify any limitations in functioning that result for the condition(s) or disorder(s), including the claimant’s ability to:

1. Understand, carry out, and remember instructions (both complex and one-two step);

2. Sustain concentration and persist in work-related activity at a reasonable pace;

3. Maintain effective social interaction on a consistent and independent basis, with supervisors, co-workers, and the public; and

4. Deal with normal pressures in a competitive work setting.


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0422510112
DI 22510.112 - Adult Consultative Examination (CE) Report Content Guidelines for Mental Disorders - 09/25/2020
Batch run: 09/25/2020
Rev:09/25/2020