Effective Dates: 05/15/2015 - Present Previous | Next

TN 23 (09-20)

DI 22510.043 Pediatric Consultative Examination (CE) Report Content Guidelines for Hematological Disorders

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.

A. General guidelines for CE report content to pediatric hematological disorders

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.

B. Report content specific to pediatric hematological disorders

Use the specific requirements below to complete the CE report for a hematological disorder.

1. Current medical history

The CE provider will describe and discuss, as appropriate:

  1. a. 

    Fatigue;

  2. b. 

    Anorexia;

  3. c. 

    Pain crises;

  4. d. 

    Headaches;

  5. e. 

    Weight loss or gain;

  6. f. 

    Edema;

  7. g. 

    Jaundice;

  8. h. 

    Ecchymoses bleeding;

  9. i. 

    Frequency of hospitalizations;

  10. j. 

    Hemoglobin values;

  11. k. 

    Infections; and

  12. l. 

    Frequency of red blood cell (RBC) or other blood component transfusions or infusions.

2. Physical examination

The CE provider will describe and discuss, as appropriate:

  1. a. 

    Any apparent abnormalities such as enlarged lymph nodes, edema, fatigue level, abnormal bruising, pallor, scleral icterus, and jaundice;

  2. b. 

    Evidence of bleeding – ecchymoses, petechiae, and hemarthrosis;

  3. c. 

    Liver and spleen size; and

  4. d. 

    Abnormal neurological findings.

To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0422510043
DI 22510.043 - Pediatric Consultative Examination (CE) Report Content Guidelines for Hematological Disorders - 05/15/2015
Batch run: 09/25/2020
Rev:05/15/2015