TN 22 (09-20)

DI 22510.100 General Guidelines for Adult Physical Consultative Examination (CE) Report Content

The following are guidelines to provide minimum content for CE reports for adult claimants. Each Disability Determination Services (DDS) will notify medical sources of any additional requirements.

A. 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 photographic 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, 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.

B. 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, and

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

2. Current medical history

The CE provider will describe and discuss as appropriate:

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(s) and/or impairment(s);

2. The claimant’s statement of current symptoms;

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. Dates and results of relevant hospitalizations, surgical operations, and diagnostic procedures (for example, audiometry, tympanography, MRI).

3. Past medical history

The CE provider will describe and discuss, as appropriate, any other significant past illnesses, injuries, operations, hospitalizations, and diagnostic procedures with dates of the events, and when possible, the names of the treatment providers or facilities.

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.

5. Review of systems

The CE provider will describe and discuss other symptoms the claimant has experienced relative to any specific organ systems; and the pertinent negative findings considered in making a differential diagnosis of the current illness or in evaluating the severity of this or any other alleged impairment.

6. Social history

The CE provider will include pertinent findings about use of tobacco products, alcohol, and nonprescription drugs, etc., as well as relevant work history such as occupations with exposure to hazards.

7. Family history

The CE provider will include the relevant information.

C. Physical examination and other objective findings

1. Physical examination

The CE provider will describe and discuss as appropriate:

a. General observations, such as how the claimant arrived at the examination, whether they were alone or accompanied, the distance they traveled, and if they arrived by automobile, who drove;

b. General appearance (including any obvious vision or hearing loss, and facial, skeletal, or other abnormalities);

c. Blood pressure, pulse rate and rhythm, respiratory rate;

d. Nutritional status (including height and weight without shoes, including the presence and impact of obesity, if appropriate);

e. Behavior (such as cooperativeness and effort on testing, as appropriate); and

f. A thorough and complete physical examination, with aspects of the examination focusing on the claimant’s major and minor complaints in detail, describing both pertinent positive and negative findings.

2. Laboratory and imaging tests (for example, x-ray)

a. The CE provider will obtain only after proper authorization from the DDS.

b. The CE provider will provide an interpretation of laboratory and imaging tests.

1. The CE provider will provide interpretation that takes into account, and correlates with, the history and physical examination findings.

2. If the interpretation is provided separately, or if a medical source other than the person signing the CE report is providing the formal interpretation of the results, the report sheet should state the interpreting medical source’s name and address.

D. Medical opinion

1. The medical source should provide a medical opinion

The CE provider will assess the claimant’s ability to perform the demands of work activities, and any limitations based upon the claimant’s medical history, medical signs and observation during the examination, and results of relevant laboratory and imaging tests.

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 and/or in the examination findings; and

c. The CE provider will specify any limitations in functioning that result from the condition(s) or disorder(s), including:

1. Lifting, carrying, pushing, pulling;

2. Sitting, standing, walking;

3. Postural (for example: climbing, stooping, bending, balancing, crawling, kneeling and/or crouching);

4. Fine or gross motor skills (for example: handling, fingering, gripping, and/or feeling);

5. Overhead, lateral, and forward reaching;

6. Vision, hearing, and speech; and

7. Environmental exposures (for example: extreme heat, extreme cold, wetness, humidity, noise, vibration, and hazards).

To Link to this section - Use this URL:
DI 22510.100 - General Guidelines for Adult Physical Consultative Examination (CE) Report Content - 09/25/2020
Batch run: 09/25/2020