TN 35 (10-23)
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.
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.
The CE provider will use the specific requirements below to complete the CE report for a digestive disorder.
The CE provider will describe and discuss, as appropriate:
Fatigue, muscle weakness, sensory abnormalities, cognitive impairment, malaise, and/or loss of appetite;
Sleep disturbance and any other nocturnal symptoms;
Pain, if present, and its location;
Eating habits, and unusual weight loss or gain;
Bowel and bladder patterns;
Rectal bleeding, if the claimant allows the physician to observe the rectum;
Nausea;
Growth failure; and
Dates and results of relevant diagnostic procedures (such as diagnostic imaging, endoscopy, biopsy, aspiration of ascetic fluid, and clinical laboratory test).
Length, height, and weight;
Nutritional status;
Presence of jaundice and pallor;
Liver and spleen size;
Muscle wasting;
Presence of edema, ascites, and asterixis;
Presence of any abdominal masses; and
Evidence of perianal disease.
The CE provider will describe and discuss, as appropriate. Laboratory testing should include, if appropriate:
Serum creatinine;
Serum total bilirubin;
International normalized ratio (INR);
Serum albumin; and
Hemoglobin.