Part V - Adult Consultative Examination Report Content Guidelines

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.

Identification
1. The CE provider will include the claimant's name, date of birth, and/or claim number; and,
2. Indicate that the claimant and/or caregiver provided proof of identity by showing an original document proving age and identity (social security card, U.S. passport, birth certificate, student or school ID, daycare center or school record); or,
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.
Medical History
1. Longitudinal medical history
  1. The CE provider will cite and describe the medical records and any other documents reviewed during the course of the evaluation, and
  2. 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:
  1. 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).
  2. 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
  1. 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;
  2. Early infant or preschool intervention services;
  3. For children who have not attained age 6, developmental milestones (for example, the results of a formalized developmental screening test)
  4. For children age 6 and older, usual daily activities; and
  5. 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.
Physical examination and other objective findings
1. Physical examination
  
  The CE provider will describe and discuss, as appropriate:
  1. 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;
  2. Blood pressure, pulse rate and rhythm, and respiratory rate;
  3. General appearance including any obvious vision or hearing loss, and facial, skeletal, or other abnormalities;
  4. The interaction with the CE provider, including the ability to understand directions and communicate clearly with content appropriate for age;
  5. General pediatric examination and body system specific examination as needed;
  6. A thorough and complete physical examination addressing the child’s major and minor complaints in detail, with both pertinent positive and negative findings; and,
  7. Cooperation and/or effort as appropriate.
2. Laboratory and imaging tests (for example, x-ray)
  1. The CE provider will obtain only after proper authorization from the DDS; and
  2. 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.
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:
  1. Specify the nature and extent of the condition or disorder;
  2. Discuss any apparent discrepancies in the medical history or in the examination findings; and
  3. Specify any limitations in functioning that result from the condition(s) or disorder(s).

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Pediatric - Musculoskeletal 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.

General guidelines for CE report content for pediatric musculoskeletal disorders

The guidelines in this section are in addition to the Pediatric CE report content as stated in General Pediatric Consultation Examination Report.
Report content specific to pediatric musculoskeletal disorders

The CE provider will use the specific requirements below to complete the CE report for a musculoskeletal disorder.
1. Current medical history
  
  The CE provider will describe and discuss, as appropriate:
  1. Character, location, and radiation of pain;
  2. Factors that incite and relieve the pain;
  3. Symptoms of weakness, other motor loss, and/or any sensory abnormalities; and
  4. Dates and results of any relevant diagnostic procedures, such as x-rays, myelography, CT scan, MRI, and radionuclide bone scan.
2. Physical examination
  
  The CE provider will describe and discuss, as appropriate:
  1. Any apparent abnormalities such as gait, or the need for any type of assistive device;
  2. Extremities and peripheral joints:
    1. Active and passive range of motion;
    2. If active range of motion is abnormal, describe passive range of motion and how active range of motion differs from passive range of motion;
    3. Effusion;
    4. Peri-articular swelling;
    5. Pain, if any, and its distribution;
    6. Tenderness;
    7. Redness or heat;
    8. Thickening;
    9. Structural deformities;
    10. Instability;
    11. Grip, pinch, ability to close the fist or perform fine and gross manipulations (measured either by dynamometer or 0-5 scale);
    12. Extremity strength (measured either by dynamometer or 0-5 scale);
    13. Atrophy; and
    14. Ability to use, and effective use of, any orthoses.
  3. Spine:
    1. Distribution of pain, tenderness, and sensory and/or motor loss;
    2. Intensity and symmetry of deep tendon reflexes;
    3. Muscle spasms, when present;
    4. Active range of spinal motion;
    5. When the lumbar spine is an issue, straight-leg raising (lumbar spine, both sitting and supine); and,
    6. When the cervical spine is an issue, provocation test for radiculopathy, such as the Sperling test.
  4. Amputated extremities:
    1. Description of stump, including integrity of skin flap;
    2. Tenderness; and
    3. Ability to use, and effective use of, any prostheses. It is not necessary to evaluate the child’s ability to walk without the prostheses in place. If an upper extremity is involved, the CE provider should comment on the functional level of the contralateral extremity.
  5. Fractures of bones of extremities or pelvis:
    1. Review of imaging such as x-rays or MRI; and
    2. Clinical evidence of union or non-union.
  6. Soft tissue injuries/burns:
    1. Nature and extent of the injury;
    2. Skin sensitivity; and
    3. Effect the injury has on joint motion.

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Pediatric - Special Senses and Speech

General guidelines for CE report content for pediatric special senses and speech disorders

The CE report content guidelines in this section are in addition to the general pediatric CE report content guidelines. See General Pediatric Consultation Examination Report. For pediatric CE report content guidelines for speech disorders and language disorders, see Pediatric - Speech and Language (SL) Impairments in Children from Birth to Attainment of Age 3 and See Pediatric - Speech and Language (SL) Impairments in Children Age 3 and Older
Report content specific to pediatric visual disorders

The CE provider will use the specific requirements below to complete the CE report for a visual disorder.
1. Current medical history
  
  The CE provider will describe and discuss, as appropriate:
  1. Character and severity of visual loss;
  2. Dates and results of relevant diagnostic procedures, such as imaging studies, visual acuity testing, and visual field testing.
2. Physical examination
  
  The CE provider will describe and discuss, as appropriate:
  1. Best corrected visual acuity for each eye, and the manifest refraction for each eye.
    1. If there is a loss of visual acuity, document the cause of the loss.
    2. If the vision loss is due to a cortical visual disorder, it must be confirmed by documenting the cause of the brain lesion.
  2. For children who do not have the ability to participate in visual acuity testing using Snellen methodology or other comparable testing, clinical findings of fixation and visual-following behavior.
  3. Examination of pupils, external exam, and extraocular motions.
  4. Visual fields – confrontation visual fields.
    1. If confrontation fields are not normal, or if there is a history of glaucoma, visual field testing is needed;
    2. Confrontation fields are acceptable evidence that the fields are normal. Restricted fields must be confirmed either by acceptable automated static threshold perimetry, measuring the central 24 to 30 degrees of the visual field performed on an acceptable perimeter (acceptable test include the Humphrey Field Analyzer (HFA) 30-2, Octopus 32, Octopus 30-2, and HFA 24-2); or an acceptable manual or automated kinetic perimetry (for example, Goldmann perimetry);
    3. Include a printout of any visual field testing (perimetry) results; and
    4. If there is a loss of visual fields, document the cause of the loss.
  5. Intraocular pressure for each eye;
  6. Slit lamp exam – cornea and lens, at least;
  7. Fundus exam – discs, vessels, and maculae, and peripheral retina; and,
  8. Any observed visual behaviors (for example, ability to navigate in the office, reaching for items, using cell phone in waiting room, etc.).
Report content specific to pediatric hearing loss
1. Current medical history
  
  The CE provider will describe and discuss, as appropriate:
  1. Character and severity of hearing loss; and
  2. Dates and results of relevant diagnostic procedures, such as audiometry, tympanogram/tympanometry, and MRI.
2. Physical examination
  
  The CE provider will describe and discuss as appropriate:
  1. Examination of the ears, nose, and throat;
  2. An otologic examination:
    1. The external ears (pinnae and external ear canals) and the tympanic membranes; and
    2. Any middle ear abnormalities
  3. Hearing loss:
    1. The condition that causes the hearing loss; and
    2. Whether the hearing loss is sensorineural, conductive, or mixed.
  4. All audiometric testing performed where no cochlear implant or bone-anchored hearing aid (BAHA) is present should be conducted unaided.
  5. For children without a cochlear implant(s) from birth to the attainment of age 6 months, physiologic testing, such as auditory brainstem response (ABR) testing.
  6. For children without a cochlear implant(s) who are age 6 months to the attainment of age 2, air conduction thresholds determined by a behavioral assessment, usually visual reinforcement audiometry (VRA) or ABR testing, if the behavioral assessment cannot be completed.
  7. For children without a cochlear implant(s) who are age 2 to the attainment of age 5, air conduction thresholds determined by a behavioral assessment, such as conditioned play audiometry (CPA), tangible or visually reinforced operant conditioning audiometry (TROCA, VROCA), or VRA.
  8. For children without a cochlear implant(s) who are age 5 and older:
    1. Pure tone air conduction and bone conduction testing, speech recognition threshold (SRT) testing, and word recognition testing;
    2. Testing must be done in a sound-treated booth or room;
    3. Testing must be done in accordance with the most recently published standards of the American National Standards Institute (ANSI);
    4. Each ear must be tested separately; and
    5. If the SRT is not within 10 dB of the average pure tone air conduction thresholds at 500, 1,000, and 2,000 Hz, document the medical basis for the discrepancy.
  9. For children with a cochlear implant(s) who are age 5 and older:
    1. Sentences presented at 60 dB hearing level and without any visual cues;
    2. In a quiet and sound field; and
    3. With the cochlear implant in place, functioning properly, and adjusted to the child's normal settings.

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Pediatric - Respiratory Disorders

General guidelines for CE report content for pediatric respiratory disorders

The CE report content guidelines in this section are in addition to the general pediatric CE report content guidelines. See General Pediatric Consultation Examination Report.
Report content specific to pediatric respiratory disorders

The CE provider will use the specific requirements below to complete the CE report for a respiratory disorder.
1. Current medical history
  
  The CE provider will describe and discuss, as appropriate:
  1. Dyspnea at rest and with exertion;
  2. Palpation, wheezing, cough, sputum production, chest discomfort, symptoms of hyperventilation, paroxysmal nocturnal dyspnea, and orthopnea;
  3. Characteristics of severe respiratory attack or persistent pulmonary infection;
  4. History of hospitalizations or emergency department visits; and
  5. Episodic disorders, such as asthma:
    1. Onset and precipitating factors;
    2. Frequency and intensity;
    3. Duration;
    4. Mode of treatment and response; and
    5. Description of severe attack(s).
2. Physical examination
  
  The CE provider will describe and discuss, as appropriate:
  1. Assistive devices: presence of tracheostomy, central venous catheter, supplemental oxygen, or gastrostomy;
  2. Respiratory rate: whether respirations are labored, and use of any accessory muscles of respiration;
  3. Lungs:
    1. Occurrence of cough, audible wheezing, pallor cyanosis, hoarseness, clubbing of fingers, chest wall deformity, and any abnormal curvature of the spine;
    2. Whether there is prolongation of the expiration phase of respiration;
    3. Quality of breath sounds (or air exchange), whether normal or diminished;
    4. Presence or absence of adventitious sounds (such as wheezing, rhonchi, or rales); and
    5. Diaphragmatic motion.
  4. Heart and vascular:
    1. Description of heart sounds;
    2. Presence of any lifts, heaves, or thrills;
    3. Heart size;
    4. Point of maximal impact of cardiac apex;
    5. Presence of any murmurs, rubs or gallops;
    6. Distention of neck veins; and
    7. Presence, type, and extent of any peripheral edema and any associated skin discoloration or ulceration;
  5. Pulmonary Function Tests. The CE provider will obtain pulmonary function tests only after receiving proper authority from the DDS. Perform spirometry testing for children age six and older as specified in section 103.00E of the respiratory listing (see https://www.ssa.gov/disability/professionals/bluebook/103.00-Respiratory-Childhood.htm.)

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Pediatric - Cardiovascular Disorders

General guidelines for CE report content for pediatric cardiovascular disorders

The CE report content guidelines in this section are in addition to the general pediatric CE report content guidelines. See General Pediatric Consultation Examination Report.
Report content specific to pediatric cardiovascular disorders

The CE provider will use the specific requirements below to complete the CE report for a cardiovascular disorder.
1. Current medical history
  
  The CE provider will describe and discuss, as appropriate:
  1. Dyspnea;
  2. Orthopnea;
  3. Exercise intolerance;
  4. Hypercyanotic spells;
  5. Slow feeding;
  6. Squatting;
  7. Syncope; and
  8. Growth failure.
2. Physical examination
  
  The CE provider will describe and discuss, as appropriate:
  1. Whether respiratory rate is labored or unlabored;
  2. O2 saturation level;
  3. Evidence of cyanosis (perioral, peripheral), pallor, and clubbing;
  4. Heart sounds and murmurs;
  5. Presence of hepatomegaly and edema; and,
  6. Exercise tolerance test (ETT). The CE provider will obtain ETT only after receiving proper authorization from DDS. Use ETT for children age 6 and older, and perform as specified in section 104.00B7 of the cardiovascular listing (see https://www.ssa.gov/disability/professionals/bluebook/104.00-Cardiovascular-Childhood.htm.)

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Pediatric - Digestive Disorders

General guidelines for CE report content for pediatric digestive disorders

The CE report content guidelines in this section are in addition to the general pediatric CE report content guidelines. See General Pediatric Consultation Examination Report.
Report content specific to pediatric digestive disorders

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

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Pediatric - Genitourinary Disorders

General guidelines for CE report content for pediatric genitourinary disorders

The CE report content guidelines in this section are in addition to the general pediatric CE report content guidelines. See General Pediatric Consultation Examination Report.
Report content specific to pediatric genitourinary disorders

The CE provider will use the specific requirements below to complete the CE report for a genitourinary disorder.
1. Current medical history
  
  The CE provider will describe and discuss, as appropriate:
  1. Malaise;
  2. Fatigue;
  3. Poor appetite;
  4. Edema;
  5. Headaches;
  6. Bone pain;
  7. Urinary frequency, dysuria, hematuria, and/or incontinence;
  8. Renal ultrasound results;
  9. Type and frequency of urological procedures; and
  10. Acute weight gain or loss.
2. Physical examination
  
  The CE provider will describe and discuss, as appropriate:
  1. Pallor;
  2. Fundoscopic and any retinal change;
  3. Edema – type and location;
  4. Anasarca;
  5. Congenital abnormalities; and
  6. Neurological findings – irritability and hypotonia.

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Pediatric - Hematological Disorders

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. See General Pediatric Consultation Examination Report.
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. Fatigue;
  2. Anorexia;
  3. Pain crises;
  4. Headaches;
  5. Weight loss or gain;
  6. Edema;
  7. Jaundice;
  8. Ecchymoses bleeding;
  9. Frequency of hospitalizations;
  10. Hemoglobin values;
  11. Infections; and
  12. 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. Any apparent abnormalities such as enlarged lymph nodes, edema, fatigue level, abnormal bruising, pallor, scleral icterus, and jaundice;
  2. Evidence of bleeding – ecchymoses, petechiae, and hemarthrosis;
  3. Liver and spleen size; and
  4. Abnormal neurological findings.

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Pediatric - Skin Disorders

General guidelines for CE report content for pediatric skin disorders

The CE report content guidelines in this section are in addition to the general pediatric CE report content guidelines. See General Pediatric Consultation Examination Report.
Report content specific to pediatric skin disorders

The CE provider will use the specific requirements below to complete the CE report for a skin disorder.
1. Current medical history
  
  The CE provider will describe and discuss, as appropriate:
  1. Dates of relevant diagnostic procedures such as biopsy and genetic testing;
  2. Results of relevant diagnostic procedures;
  3. Treatment modalities, dates of treatments, and responses to treatments;
  4. Frequency, severity, and duration of skin lesion exacerbations;
  5. Effects on age-appropriate activity, especially social behavior, because of disfigurement; and
  6. If the claimant uses a lower extremity assistive device, note whether the assistive device was prescribed, how frequently it is used, the date it was prescribed, and the medical source who prescribed it.
2. Physical examination
  
  The CE provider will describe and discuss, as appropriate:
  1. Location, size, and appearance of skin lesion(s) and contractures, associated symptoms such as pain or tenderness, and extent of the body affected (e.g., one or both extremities).
  2. Joint function including range of motion of the affected joint(s); and
  3. If at least one extremity is affected (including involvement of the perineum or inguinal region affecting lower extremity functioning), describe ability to:
    1. Perform age-appropriate gross (e.g., reaching, lifting, carrying, handling, and gripping) and fine (e.g., picking, pinching, manipulating, and fingering) movements;
    2. Stand up from a seated position; and
    3. Maintain an upright position while standing or walking.
  4. Provide a description of the claimant’s gait. If the claimant uses a lower extremity assistive device, describe:
    1. Claimant’s gait with and without use of the device; and
    2. The device and how it is used by the claimant, the medical need for the device, the medical impairment the device is needed for, and the examination findings that support the medical need for the assistive device; and
  5. Optional with consent of the claimant/guardian: a digital photograph to document the severity of the skin lesion(s).

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Pediatric - Endocrine Disorders

General guidelines for CE report content for pediatric endocrine disorders

The CE report content guidelines in this section are in addition to the general pediatric CE report content guidelines. See General Pediatric Consultation Examination Report.
Report content specific to pediatric endocrine disorders

The CE provider will use the specific requirements below to complete the CE report for an endocrine disorder.
1. Current medical history
  
  The CE provider will describe and discuss, as appropriate:
  1. Fatigue;
  2. Drowsiness;
  3. Gastroparesis;
  4. Any vision loss or other visual changes;
  5. Heat or cold intolerance;
  6. Sensory aberrations;
  7. Hypoglycemia unawareness;
  8. Convulsions, tetany, or episodes of alteration of consciousness;
  9. Bone pain or localization of pain;
  10. Increased thirst;
  11. Abdominal pain;
  12. Abnormal bowel or urinary tract changes, including change in frequency;
  13. Growth failure or weight loss;
  14. Hospitalizations due to diabetic ketoacidosis; and
  15. Dates and results of relevant diagnostic procedures, such as CBC, liver enzymes, adrenal function, serum electrolytes, calcium and phosphorus, fasting blood glucose, glucose tolerance testing, Hb1AC, blood chemistries, T3, TSH, urinalysis, and relevant imaging studies.
2. Physical examination
  
  The CE provider will describe and discuss, as appropriate:
  1. Abnormal sweating, dry skin, or changes in color or texture of skin;
  2. Abnormal eye changes, such as exophthalmia, visual field loss, extra ocular muscle movement, and fundus changes (retinitis proliferans);
  3. Abnormal masses of neck or abdomen;
  4. Assessment of reflex activity and muscle strength;
  5. Presence of tremulousness, Chvostek, or Trousseau signs; and
  6. Mental status.

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Pediatric - Neurological Disorders

General guidelines for the CE report content for pediatric neurological disorders

The CE report content guidelines in this section are in addition to the general pediatric CE report content guidelines. See General Pediatric Consultation Examination Report.
Report content specific to pediatric neurological disorders

The CE provider will use the specific requirements below to complete the CE report for a neurological disorder.
1. Current medical history
  
  The CE provider will describe and discuss, as appropriate:
  1. Use of assistive devices(s) or brace(s) being used, when they are used, and who prescribed their use;
  2. Complete description of seizures including type and severity, aura, behavior prior to seizure, diurnal or nocturnal, frequency per month during the past year, duration of episodes, postictal phenomena, and date of last three seizures;
  3. Cognitive impairment;
  4. For children under age 6, a history of developmental milestones;
  5. Motor weakness;
  6. Sensory aberrations;
  7. Problems with speech;
  8. Problems with swallowing;
  9. Problems with voiding and defecation; and
  10. Headaches including known triggers, frequency, length and response to treatment.
2. Physical examination
  
  The CE provider will describe and discuss, as appropriate:
  1. Hand dominance;
  2. Cranial nerve evaluation, including the ability to fix and follow for vision;
  3. Motor strength and how tested, reflexes, muscle bulk, and tone;
  4. For children who cannot participate in muscle strength testing, record observations of abilities such as rolling over, sitting, pulling, and standing;
  5. Abnormal movements;
  6. Gait and fine motor coordination;
  7. Sensation and how tested;
  8. Assistive device(s) or brace(s) brought to examination with description and opinion regarding its medical necessity;
  9. Mental status examination: details about the mental status examination, as appropriate based on child's age; and
  10. Speech functioning, including:
    1. Intelligibility and fluency;
    2. Aphasia;
    3. Dysarthria;
    4. Stuttering; and
    5. Involuntary vocalizations.

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Pediatric - Mental Disorders

General guidelines for CE report content for pediatric mental disorders

The CE report content guidelines in this section are in addition to the general pediatric CE report content guidelines. See General Pediatric Consultation Examination Report.
Identification
1. The CE provider will include the claimant's name, date of birth, and/or claim number; and
2. Indicate that the claimant and/or caregiver provided proof of identity by showing an original document proving age and identity (social security card, U.S. passport, birth certificate, student or school ID, daycare center or school record); or
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.
Medical History
1. Longitudinal medical history
  
  The CE provider will describe and discuss, as appropriate:
  1. Cite the specific medical records and any other documents reviewed during the course of the evaluation; and
  2. Identify the person(s) providing the oral medical history and an assessment of the validity and reliability of such information.
2. Current medical history
  
  The CE provider will describe and discuss, as appropriate:
  1. The primary impairment(s) alleged for which the disability claim is being filed;
  2. Onset, frequency, and duration of the impairment(s);
  3. Current treatment plan including medicines and dosages, role of child and caregiver in administration of treatment plan, need for periodic adjustments in medication regimen;
  4. Special therapy, equipment or devices;
  5. Response to treatment and overall extent of control of the impairment(s); and
  6. Source(s) of medical care including specialist(s) or specialty clinic(s).
3. Past medical history
  
  The CE provider will describe and discuss, as appropriate:
  1. Prenatal, delivery, and neonatal course; and
  2. Other significant events including past illnesses, injuries, operations, hospitalizations, and urgent care encounters. When possible provide the dates of events and names of facilities that provided treatment.
4. Information about the child's development
  
  The CE provider will describe and discuss, as appropriate:
  1. For children who have not attained age 6, developmental milestones – the results of a formalized developmental screening test is one method to meet this requirement;
  2. Early infant or preschool intervention services;
  3. For children age 6 and older, usual daily activities; and
  4. Current grade, type of class, limitations of activities, and need for special assistance or extra care.
5. Provide a list of 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.
Infants and toddlers (birth up to age 3)

Information on the mental assessment for infants and toddlers must include the following:
1. Motor coordination and responsiveness to visual, auditory, and tactile stimuli (birth to 12 months)
2. Communicative behaviors, including pre-speech behaviors (for example, sucking, swallowing, imitation of sounds) and early language behaviors (for example, jargon, single words, phrases, turn-taking);
3. Manner of relating to and interacting with parent or caregiver, and ability to separate from parent or caregiver;
4. Manner of relating to and interacting with sibling or peer group, if observed;
5. Any stereotypical movements;
6. Perceptual functioning; and
7. Other pathology.
Children age 3 and older

Information on the mental assessment for children age 3 and older must include the following:
1. History, including adjustment in school and home (daily activities, social functioning, concentration, persistence, pace);
2. Appearance and grooming;
3. Behavior;
4. Attention and concentration;
5. Affect;
6. Communicative abilities and behavior;
7. Thought processes (with verbatim examples);
8. Cognitive functioning, including psychological test findings;
9. Any indication of self-injury; and
10. Any indication of substance use.
Mental status examination for children age 12 and older

The mental status examination for individuals in this age range must include the information for children age 3 and older. The case facts emphasized will determine the specific areas of mental status during the examination, but the report must include a detailed description of the child's:
1. Judgment and insight;
2. Impulse control;
3. Orientation;
4. Memory; and
5. Homicidal and suicidal ideation.
Diagnosis

The CE 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.

NOTE: The description of the claimant's mental status must not be an enumeration of the symptoms reported by the claimant (or other source); rather the description must be the examining source's description of the above item.
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.
Additional requirements for intellectual disability

The CE report must describe the following:
1. Current documentation of IQ score by a standardized, well-recognized measure. Acceptable instruments will have a representative normative sample, a mean of approximately 100 and standard deviation of approximately 15 in the general population, and cover a broad range of cognitive and perceptual-motor functions (for example, the Wechsler scales);
2. Summary of composite scores (for example, Full Scale IQ, Verbal Comprehension Index, Perceptual Reasoning Index) together with the individual subtest scores;
3. Interpretation of the scores and assessment of the validity of the obtained scores, indicating any factors that may have influenced the results, such as the child'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
4. Consistency of the obtained test results with the child’s education and social adjustment, especially in the area of personal self-sufficiency.
Provide a medical opinion

The medical source should provide a medical opinion that includes the following:
1. Assessment of the child’s abilities and limitations based upon the child’s medical history, observations during the examination, and results of relevant signs or tests, or both;
2. Specify the nature and extent of the condition or disorder;
3. Discuss any apparent discrepancies in the medical history or in the examination findings; and
4. Specify any limitations in age-appropriate functioning that result from the condition or disorder, including the child’s ability to:
  1. Acquire and use information;
  2. Interact and relate with others;
  3. Attend and complete tasks; and
  4. Care for himself or herself.

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Pediatric - Cancer

General guidelines for CE report content for pediatric cancer

The CE report content guidelines in this section are in addition to the general pediatric CE report content guidelines. See General Pediatric Consultation Examination Report.
Report content specific to pediatric cancer

The CE provider will use the specific requirements below to complete the CE report specific to cancer.
1. Current medical history
  
  The CE provider will describe and discuss as appropriate:
  1. Fatigue, malaise, and/or affected organ systems;
  2. Type of therapy received or planned, including prescribed medications and their side effects (for each cancer condition if more than one). If multimodal therapy, dates each therapy was completed/scheduled and performed by which physician;
  3. Effects of any post-therapeutic residuals;
  4. Planned treatment;
  5. Weight loss;
  6. Prognosis, if available; and
  7. Dates and results of relevant diagnostic procedures, such as biopsy or tissue pathologic examination and imaging studies, as these results relate to information on cancer stage, when possible.
2. Physical examination
  
  The CE provider will describe and discuss as appropriate:
  1. Review of any biopsy or tissue pathologic examination;
  2. Imaging studies; and
  3. Other body systems affected by adverse effects of treatment.

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Pediatric - Immune System Disorders

General guidelines for CE report content for pediatric immune system disorders

The CE report content guidelines in this section are in addition to the general pediatric CE report content guidelines. See General Pediatric Consultation Examination Report.
Report content specific to pediatric immune system disorders

The CE provider will use the specific requirements below to complete the CE report for an immune system disorder.
1. Current medical history
  
  The CE provider will describe and discuss, as appropriate:
  1. Weight loss;
  2. Fever;
  3. Pain;
  4. Fatigue;
  5. Malaise;
  6. Type, frequency, and severity of any infections, especially systemic infections – sepsis, meningitis, endocarditis, osteomyelitis;
  7. Stem cell transplantation and any adverse effects; and
  8. Difficult to control dermatologic conditions.
2. Physical examination
  
  The CE provider will describe and discuss, as appropriate:
  1. Signs of affected body systems, such as heart, lungs, kidneys, eyes, digestive system, skin, etc.;
  2. Temperature;
  3. Joint pain, swelling, tenderness, contractures, deformities;
  4. Muscle weakness, atrophy, pain;
  5. Skin abnormalities; and
  6. Extra-articular findings.

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Pediatric - Speech and Language (SL) Impairments in Children from Birth to Attainment of Age 3

General guidelines for CE report content for pediatric speech and language disorders

The CE report content guidelines in this section are in addition to the general pediatric CE report content guidelines. See General Pediatric Consultation Examination Report.
Report content specific to pediatric speech disorders and language disorders

The CE provider will describe and discuss, as appropriate:
1. The alleged speech or language problems;
2. The ages at which the child babbled, produced first words, and spoke in phrases or sentences;
  
  NOTE: The DDS will provide the speech language pathologist (SLP) vendor with the child’s corrected chronological age for prematurity for any child who has not attained age 1 and for any child age 1 and older for whom the DDS continues to regard prematurity as a relevant factor to the case.
3. The characteristics of any unusual early feeding and eating behavior (for example, difficulty chewing, swallowing, or tolerating various food textures or temperatures);
4. Significant history of:
  1. Ear infections or hearing loss;
  2. Whether the child has had pressure equalizing (PE) tubes inserted and, if so, when;
  3. Other developmental problems; and
  4. Oro-maxillo-facial abnormalities and relevant surgeries.
5. Participation in previous or current speech and language therapy and progress made; and
6. The child's native language and the language(s) spoken in the home, the percentage of each language spoken in the home (and how many hours a week the child is with a daycare provider), and any exposure to language in a preschool program (and how many hours in a week in the program).
Report content specific to a speech assessment

On the CE report specific to the speech assessment, the CE provider will provide data about the child’s level of functioning and select one of two approaches to the speech assessment:
1. A statement indicating that the child’s functioning in sound production and articulation and voice is within normal limits; or
2. Information in b.1 or b.2 below, according to the component(s) of speech requiring detailed evaluation:
  1. When sound production and articulation is evaluated in detail, the report should include information (as age-appropriate) regarding:
    1. Structure and functioning of the oral mechanism.
    2. The child’s typical mode of communication (for example, uses gestures only, uses verbalization only, uses a combination of gestures and spoken language and, if so, what percentage of time for each).
    3. Sounds in the child’s repertoire, frequency, and ease of use.
    4. Sound play (such as pitch variations, “raspberry” productions, or producing animal sounds).
    5. The stage of the child’s sound making (such as cooing, reduplicative babbling, or word approximations).
    6. Test results, if applicable (full test title, test and subtest means and standard deviations, child’s standard score and subtest scores).
    7. Articulation errors or phonological processes (with examples), based on either a formal assessment tool or a speech sample.
    8. Whether sound patterns are typical, atypical, or delayed for chronological age.
    9. Level of stimulability for error sounds.
    10. Overall intelligibility percentage (not a range) as judged by the SLP (generally an unfamiliar, trained listener) if the child is using words, and whether it is within expectancy for age.
    11. A parent’s or caregiver’s estimate of the child’s intelligibility for single words in context, single words out of context, phrases or short utterances in context, and phrases or short utterances out of context.
    12. The extent to which any motor-based speech disorders (such as dyspraxia or dysarthria) limit intelligibility, as appropriate.
    13. Brief clinical observations, descriptions of voice, and speech fluency.
  2. When voice is evaluated in detail, the report should include information regarding:
    1. Structure and functioning of the oral mechanism.
    2. The child’s typical mode of communication (for example, uses gesture only, uses verbalization only, uses a combination of gesture and spoken language and, if so, what percentage of time for each).
    3. Any otolaryngological findings provided by the DDS (briefly), to keep internal consistency (per 20 CFR 404.1519(a)(2)) or a statement regarding unavailability of this information.
    4. The SLP’s assessment of vocal pitch, quality, resonance, and intensity (including whether the child is able to sustain phonation and whether conversational speech is audible).
    5. The SLP’s judgment regarding the clinical severity of the voice disorder.
    6. Brief clinical observations and descriptions of sound production and articulation.
    7. Any effect of other medical conditions (for example, allergies) on voice
Report content specific to a language assessment

On the CE report specific to a language assessment, the CE provider will provide data about the child’s level of functioning and the following, as appropriate:
1. Administer a current, standardized, comprehensive language battery that is appropriate for the child’s age (such as the Preschool Language Scale-5). “Current” means the most recently published version of the test instrument. The test report should:
  1. State the full title of the test(s) and include the test and subtest means and standard deviations.
  2. List the child’s total language standard score (SS), area composite SSs, or age equivalents when SSs are not available.
  3. Indicate when the child’s score falls below the lowest SS provided.
  4. State whether the test results are a true representation of the child’s capabilities given their cooperation, interest, attention and concentration.
    
    NOTE: Our general expectation is that the transition to using the latest version of a test occurs no more than one year after publication.
2. Supplement formal test results with a parent report instrument (such as the MacArthur-Bates Communicative Development Inventories).
3. Document clinical observations and descriptions of the child’s:
  1. Typical mode of communication (for example, uses gesture only, uses verbalization only, uses a combination of gesture and spoken language and, if so, what percentage of time for each).
  2. Use of gestures (such as communicative pointing or showing objects).
  3. Ability to initiate and maintain social gaze or eye contact, joint attention, and turn-taking.
  4. Mean length of utterances (MLU). Obtain a language sample of at least 20 utterances, if possible, and then determine the MLU (in terms of morphemes, not words).
  5. Total number of words and word approximations in expressive vocabulary (regardless of clarity).
  6. Frequency and type (novel, stereotypic) of multi-word utterances.
  7. Range of communicative intentions (such as labeling, requesting, or socializing).
4. Document relevant information obtained through parent or caregiver report regarding the child’s language understanding and production.
5. Compare the child’s receptive and expressive language skills to those of typically developing, same-age peers, using substantive descriptions (versus a general, single statement of age-appropriateness) and provide examples.
  
  NOTE: The CE will provide any other pertinent information and observations that may be helpful in evaluating the child (for example, include information on the child’s level of cooperation, compliance, and social interaction).
SLP conclusions

The CE provider will include the following information on the CE report:
1. State conclusions and correlate them with information from the history, clinical observations, and formal assessment.
2. Explain any discrepancies between the test data and observed behaviors or, if you cannot explain the discrepancies, then comment on them.
3. Provide:
  1. A diagnosis, and
  2. A statement of whether and to what extent the SLP may reasonably expect the identified speech disorder or language disorder to impact how the child functions every day and in all settings compared to other children the same age who do not have the impairment, currently and over the next 12 months.
4. State whether norm-referenced test scores (or detailed parent or caregiver interview, if the child was reluctant to talk with the SLP) are generally consistent with observations and impressions about the child’s conversational skills (for example, oral language or social interaction) and school language skills (for example, narrative discourse).
5. Sign the report and identify their educational degree and certification or licensure credentials.

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Pediatric - Speech and Language (SL) Impairments in Children Age 3 and Older

General guidelines for CE report content for pediatric for speech and language disorders

The CE report content guidelines in this section are in addition to the general pediatric CE report content guidelines. See General Pediatric Consultation Examination Report.
Report content specific to pediatric speech disorders and language disorders

The CE provider will describe and discuss, as appropriate:
1. The alleged speech or language problems;
2. Significant history of:
  1. Ear infections or hearing loss;
  2. Whether the child has had pressure equalizing (PE) tubes inserted and, if so, when;
  3. Other developmental problems; and
  4. Oro-maxillo-facial abnormalities and relevant surgeries.
3. Participation in previous or current speech-language therapy and progress made; and
4. Indicate the child’s native language and the language(s) spoken in the home, the percentage of each language spoken in the home (and how many hours a week the child is with a daycare provider), and any exposure to language in a school program (and how many hours a week in the program).
Report content specific to a speech assessment

On the CE report specific to the speech assessment, the CE provider will provide data about the child’s level of functioning and select one of two approaches to the speech assessment:
1. A statement indicating that the child’s functioning in sound production and articulation and voice is within normal limits; or
2. The information in b.1, b.2, or b.3 below, according to the
  component(s) of speech requiring detailed evaluation:
  1. When articulation and phonological development is evaluated in detail, the report should include information (as age-appropriate) regarding:
    1. Structure and functioning of the oral mechanism (for example, diadochokinetic rates, tongue mobility and strength).
    2. Articulation errors or phonological process, usually based on a formal assessment tool, and a variety of sampling procedures (for example, connected speech sampling).
    3. Whether sound patterns are typical, atypical, or delayed for chronological age.
    4. Level of stimulability for error sounds at word or sentence level.
    5. Overall intelligibility percentage (not a range) as judged by the SLP (an unfamiliar, trained listener) if the child is using words in known or unknown context, and whether it is within expectancy for age.
    6. A parent’s or caregiver’s estimate (elicited by asking how many of ten typical utterances he or she understands) of the child’s conversational speech intelligibility on first attempt when communicating about familiar and unfamiliar topics.
    7. A parent’s or caregiver’s estimate of conversational speech intelligibility upon repetition (either spontaneously or by request).
    8. The extent to which any motor-based speech disorders (such as dyspraxia or dysarthria) limit intelligibility, as appropriate.
    9. The influence of dialectal variations on the speech pattern, as appropriate.
    10. Brief clinical observations, descriptions of voice, and speech fluency.
  2. When voice is evaluated in detail, the report should include information regarding:
    1. Structure and functioning of the oral mechanism (for example, diadochokinetic rates, tongue mobility and strength).
    2. The otolaryngologist’s findings provided by the DDS (briefly) or a statement regarding unavailability of this information.
    3. The SLP’s assessment (as guided by a clearly specified, commercially available protocol or manual) of vocal pitch, quality, and intensity (including whether the child is able to sustain phonation and whether conversational speech is audible).
    4. Observed or reported voice used patterns and how these may contribute to any identified disorder.
    5. The SLP’s judgment regarding the clinical severity of the voice disorder.
    6. Brief clinical observations and descriptions of articulation and phonology and fluency.
    7. Whether the voice is better at different times of day.
    8. Any effect of other medical conditions (for example, allergies) on voice.
    9. Effect of the voice disorder on intelligibility.
  3. When fluency is evaluated in detail, the report should include information regarding:
    1. Structure and functioning of the oral mechanism (for example, diadochokinetic rates, tongue mobility and strength).
    2. Severity rating as determined using a nationally published stuttering assessment instrument.
    3. Typical and atypical disfluencies based on parent or caregiver interview (or child interview, if appropriate), including parent and child reports regarding how often they note the two types of disfluencies in conversation with familiar and with unfamiliar listeners. (We expect that parent/child reports will more often be qualitative than quantitative.) Atypical disfluencies include part-word repetitions, audible sound prolongations, silent fixations or blockages, sound repetitions, and syllable repetitions.
    4. Observed and reported, and frequency of, secondary behaviors.
    5. How the child responds to their stuttering (such as avoiding other children during playtime or being overly anxious or fearful when interacting with others).
    6. The approximate onset date of disfluency at its current level and any changes noted over time.
    7. Brief clinical observations and descriptions (as well as the parent’s or caregiver’s report) of articulation and phonology and voice.
    8. Effect of the fluency (stuttering) disorder on intelligibility.
Report content specific to a language assessment

On the CE report specific to the language assessment, the CE provider will provide accurate data about the child’s level of functioning and the following, as appropriate:
1. Administer a current, standardized, comprehensive language battery that is appropriate for the child’s age. “Current” means the most recently published version of the test instrument. The test report should:
  1. State the full title of the test(s) and include the test and subtest means and standard deviations.
  2. List the child’s total language standard score (SS), area composite SSs, and individual subtest SSs. When a test provides quotients rather than SSs, report these instead.
  3. Indicate when the child’s score falls below the lowest SS provided.
  4. Indicate if the child needed repetition of items for tests that allow for repetition and, if so, how often.
  5. Provide an analysis, while also addressing and providing an account for any unusual scores, of the errors in the interpretation section and discuss the potential effect on school performance involving language comprehension and expression.
  6. State whether the test results are a true representation of the child’s capabilities given their cooperation, interest, attention and concentration, and any other variables that might affect performance (for example, other medical conditions, medication use or nonuse, energy and motivation).
    
    NOTE: Our general expectation is that the transition to using the latest version of a test occurs no more than one year after publication.
2. Supplement formal test results with a parent report instrument (such as the MacArthur-Bates Communicative Development Inventories), when the child’s language age falls below 36 months.
3. Based on a spontaneous language sample, document clinical observations and descriptions of the child’s overall receptive and expressive language skills. In the report, include:
  1. Information on language content and form, such as the child’s ability to follow multi-step directions, express ideas with age-appropriate mean length of utterance, use and maintain social gaze or eye contact, provide comments relevant to the discussion, ask or answer questions, and produce grammatically correct sentences for age.
  2. A description of pragmatic skills, such as the child’s ability to:
    1. Engage in verbal and nonverbal turn-taking;
    2. Initiate and maintain conversational topics;
    3. Identify and repair miscommunications;
    4. Request, respond, direct, and comment; and
    5. Retell experiences and events.
  3. Information about development of narrative skills as it relates to the child’s chronological age. For example, does a child age 6 or older produce narratives that have intact basic story structure? Does a child age 12 or older generate coherent stories using the appropriate language (such as pronouns or conjunctions) to associate elements of one sentence to those of another?
4. Document relevant information obtained through parent or caregiver report regarding the child’s language understanding and production.
5. Compare the child’s receptive and expressive language skills to those of typically developing, same-age peers, using substantive descriptions (versus a general, single statement of age-appropriateness) and provide examples.
SLP conclusions

The CE provider will include the following information on the CE report:
1. State conclusions and correlate them with information from the history, clinical observations, and formal assessment.
2. Explain any discrepancies between the test data and observed behaviors or, if you cannot explain the discrepancies, then comment on them.
3. Provide:
  1. A diagnosis, and
  2. A statement of whether and to what extent the SLP may reasonably expect the identified speech disorder or language disorder to affect the child’s ability to learn and use information and the child’s ability to interact and maintain relationships with others currently and over the next 12 months.
4. State whether norm-referenced test scores (or detailed parent or caregiver interview, if the child was reluctant to talk with the SLP) are generally consistent with observations and impressions about the child’s conversational skills (for example, oral language or social interaction) and school language skills (for example, narrative discourse).
5. Sign the report and identify their educational degree and certification or licensure credentials.

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Medical/Professional Relations

Consultative Examinations: A Guide for Health Professionals Pediatric Physical Consultative Examination Report Content

Consultative Examinations: A Guide for Health Professionals

Pediatric Physical Consultative Examination Report Content