TN 38 (03-24)

DI 22510.035 General Guidelines for Pediatric Physical Consultative Examination (CE) Report Content

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

A. Identification

  1. 1. 

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

  2. 2. 

    Indicate that the claimant and/or caregiver provided proof of identity by showing an original document proving age and identity (U.S. passport, birth certificate, student or school ID, daycare center or school record); or,

  3. 3. 

    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. 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 for the current child disability claim and explanation of how the child functions. This information must be in a narrative, rather than a “questionnaire” or “check-off” form, and pertinent descriptive statements by the claimant and/or caregiver, should be recorded in the claimant’s own words. This description must include:

1. Onset, frequency, symptoms, and duration of the impairment(s);

2. Current treatment plan including medicines and dosages, role of child and caregiver in administration of treatment plan, and need for periodic adjustments in medication regimen;

3. Special therapy, equipment, or devices;

4. Response to treatment, including medications and any side effects, and overall extent of control of the impairment(s); and

5. Source(s) of medical care including specialist(s) or specialty clinic(s).

b. Dates and results of relevant hospitalization, surgical operations, and diagnostic procedures.

3. Past medical history

The CE provider will describe and discuss, as appropriate: prenatal, delivery, and neonatal course; other significant events including past illnesses, injuries, operations, hospitalizations, prior developmental therapies, and urgent care encounters; and when possible, the dates of the events and names of facilities that provided treatment.

4. Information about the child's growth and development

a. Any delay(s) in length, height, measurement of head circumference for children under age 3, or weight growth, when impairment(s) would be expected to affect growth;

b. Early infant or preschool intervention services;

c. For children who have not attained age 6, developmental milestones (for example, the results of a formalized developmental screening test)

d. For children age 6 and older, usual daily activities; and

e. Current grade, type of class, limitations of activities, and need for special assistance or extra care.

5. Review of body 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.

7. Family history

The CE provider will include relevant information, including role of primary caretaker(s) in providing for child’s medical care and daily activity needs.

8. Current Medication(s)

The CE provider will list the child's current medication(s) by name of drug, and dose.

C. Physical examination and other objective findings

1. Physical examination

The CE provider will describe and discuss, as appropriate:

a. Length, height, and weight measurements (without shoes), as well as impact of obesity, if appropriate, head circumference for children under age 3, and percentiles based on the most recent Centers for Disease Control and Prevention growth standards;

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

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

d. The interaction with the CE provider, including the ability to understand directions and communicate clearly with content appropriate for age;

e. General pediatric examination and body system specific examination as needed;

f. A thorough and complete physical examination addressing the child’s major and minor complaints in detail, with both pertinent positive and negative findings; and,

g. Cooperation and/or effort as appropriate.

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

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

b. Provide an interpretation of laboratory and imaging tests.

1. 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. Provide a medical opinion

The CE provider will assess the child’s abilities and limitations based upon the child’s medical history, observation during the examination, and results of relevant signs, laboratory and imaging tests. The CE provider will:

a. Specify the nature and extent of the condition or disorder;

b. Discuss any apparent discrepancies in the medical history or in the examination findings; and

c. Specify any limitations in functioning that result from the condition(s) or disorder(s).


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DI 22510.035 - General Guidelines for Pediatric Physical Consultative Examination (CE) Report Content - 03/11/2024
Batch run: 03/11/2024