If the evidence provided by the claimant's own healing sources is inadequate to decree if he or she is disabled, supplementary healing facts may be sought by re-contacting the treating source for supplementary facts or clarification, or by arranging for a Ce. The treating source is the preferred source of purchased examinations when the treating source is qualified, equipped and willing to accomplish the supplementary exam or tests for the fee program cost and ordinarily furnishes unblemished and timely reports. Even if only a supplemental test is required, the treating source is ordinarily the preferred source for this service. Ssa's rules supply for using an independent source (other than the treating source) for a Ce or diagnostic study if: The treating source prefers not to accomplish the examination; there are conflicts or inconsistencies in the file that cannot be resolved by going back to the treating source; the claimant prefers another source and has a good infer for doing so; or prior palpate indicates that the treating source may not be a efficient source. The type of exam and/or test (s) purchased depends upon the definite supplementary evidence needed for adjudication. If an ancillary test (e.g., X-ray, Pfs or Ekg) will yield the supplementary evidence needed for adjudication, the Dds will not request or authorize a more wide examination. If the exam indicates that supplementary testing may be warranted, the supplier must palpate the Dds for approval before performing such testing. Fees for Ces are set by each State and may vary from State to State. Each State department is responsible for wide oversight supervision of its Ce program.
Selection of a Consultative exam Source
Differential Pressure Sensor Principle
The Dds purchases consultative examinations only from qualified healing sources. The healing source may be the individual's own doctor or psychologist, or another source. In the case of a child, the healing source may be a pediatrician.
By "qualified," we mean that the healing source must be currently licensed in the State and have the training and palpate to accomplish the type of exam or test we request. Also, the healing source must not be barred from participation in our programs. The healing source must also have the tool required to supply an adequate evaluation and narrative of the existence and level of severity of the individual's alleged impairments.
Medical professionals who accomplish Ces must have a good understanding of Ssa's disability programs and their evidence requirements. The doctor or psychologist chosen may use support staff to help accomplish the consultative examination. Any such support staff (e.g., X-ray technician, nurse, etc.) must meet standard licensing or certification requirements of the State.
Generally, sources are selected based on appointment availability, distance from a claimant's home and quality to accomplish definite examinations and tests.
Consultative exam narrative Content
The exam narrative should contain the claimant's claim whole and a corporal narrative of the claimant, to help ensure that the man being examined is the claimant.
The information and format for reporting the results of the healing history, corporal examination, laboratory findings, and conference of conclusions should consequent the standard reporting principles for a unblemished healing examination.
The narrative should be unblemished adequate to enable an independent reviewer to decree the nature, severity and duration of the impairment, and, in adults, the claimant's quality to accomplish basic work-related functions. The history and corporal exam must be provided as a narrative of the findings.
Conclusions in the narrative must be consistent with the objective clinical findings found on exam and the claimant's symptoms, laboratory studies, and demonstrated response to medicine and on all available information, including the history. The report, for adults, should contain a description, based on the provider's own findings, of the individual's quality to do basic work-related activities. It should not contain an belief as to whether the claimant is disabled under the meaning of the law.
Signature Requirements
All Ce reports must be personally reviewed and signed by the supplier who really performed the examination. The supplier doing the exam or testing is solely responsible for the narrative contents and for the conclusions, explanations or comments provided. The source's signature on a narrative annotated "not proofed" or "dictated but not read" is not acceptable. A rubber stamp signature or signature entered by another person, such as a nurse or secretary, is not acceptable.
How the Dds Reviews Consultative exam Reports
The Dds is obligated to spin the narrative of the Ce to decree whether the definite facts requested has been furnished.
The Ce narrative must:
Provide evidence that serves as an adequate basis for disability decision making in terms of the impairment it assesses.
Be internally consistent. Are all the diseases, impairments and complaints described in the history adequately assessed and reported in the clinical findings?
Do the conclusions correlate the healing history, the clinical exam and laboratory tests, and elaborate all abnormalities?
Be consistent with the other facts available within the specialty of the exam requested.
Did the narrative fail to mention an leading or relevant complaint within that specialty that is noted in other evidence in the file (e.g., blindness in one eye, amputations, pain, alcoholism, depression)?
Be adequate as compared to the standards set out in the course of a healing education.
Be properly signed.
If the narrative is inadequate or incomplete, the Dds will palpate the supplier and ask the supplier to yield the missing facts or get ready a revised report.
Elements of a unblemished Consultative Examination
A unblemished Ce is one that involves all the elements of a standard exam in the applicable healing specialty. When the narrative of a unblemished Ce is involved, the narrative should contain the following elements:
The claimant's major or chief complaint(s);
Detailed description, within the area of specialty of the examination, of the history of the major complaint(s);
Description, and disposition, of pertinent "positive" and "negative" detailed findings based on the history, examination, and laboratory tests associated to the major complaint(s), and any other abnormalities or lack thereof reported or found during exam or laboratory testing;
Results of laboratory and other tests (e.g., X-rays) performed in accordance with the requirements provided by the Dds.
Diagnosis and prognosis for the claimant's impairment(s);
Statement about what the claimant can still do despite his or her impairment(s), unless the claim is based on statutory blindness. This statement should spin the belief of the consulting doctor or psychologist about the claimant's ability, despite his or her impairment(s), to do work-related activities such as sitting, standing, walking, lifting, carrying, handling objects, hearing, speaking, and traveling; and, in cases of thinking impairment(s), the belief of the doctor or psychologist about the individual's quality to understand, to carry out and remember instructions, and to retort appropriately to supervision, coworkers, and work pressures in a work setting; and
The consultative doctor or psychologist will consider, and supply some explanation or comment on, the claimant's major complaint(s) and any other abnormalities found during the history and exam or reported from the laboratory tests. The history, examination, evaluation of laboratory test results, and the conclusions will represent the facts provided by the doctor or psychologist who signs the report.
Report article by definite Impairment
Internal Medicine
The information and format for reporting the results of the history, corporal examination, laboratory findings, and conference of conclusions should consequent the standard reporting principles for a unblemished internal healing examination.
Source of History
The doctor should indicate from whom the history was obtained and should supply an evaluation of the reliability of the history.
History of gift Illness
The chief complaint(s) alleged as the infer for not working should be discussed in detail, including:
Factors which increase the problem or impairment(s);
How long the problem has been present;
Factors which may supply relief; and
The claimant's narrative of how the impairment(s) limits the quality to function.
Pertinent descriptive statements by the claimant, such as a narrative of chest pain, should be recorded in the claimant's own words.
The facts must be in a narrative, rather than "questionnaire" or "check-off" format.
Past History should spin other prior illnesses, injuries, operations, or hospitalizations and give the dates of these events.
Current Medication should be listed by name of drug and dose.
Review of Systems should spin and discuss:
Other complaints and symptoms the claimant has experienced relative to the definite organ systems, and
The pertinent negative findings, which would be considered in making a differential prognosis of the current illness or in evaluating the severity of the impairment.
Social History should contain pertinent findings about use of tobacco products, alcohol, nonprescription drugs, etc.
Family History should be presented, if pertinent.
Signs
The vital signs should include:
Blood pressure;
Pulse rate;
Respiratory rate; and
Height and weight without shoes.
The corporal exam must supply a narrative of the claimant's general appearance and pertinent behavior during the exam (e.g., for back complaint, how the claimant stood or walked, got up from a chair, and got on and off the exam table).
This narrative must be in narrative, rather than "questionnaire" or "check-off" form.
The narrative should gift aspects of the exam dealing with the claimant's major and minor complaints in single detail, describing both pertinent negative and positive findings.
Pelvic examinations should not be performed unless specifically authorized.
Specific range of motion of a joint should be reported in degrees for joints in which there is a needful limitation of motion.
Note: If a joint is found to have no abnormality of range of motion on gross examination, that fact should be stated rather than reporting the degree of motion.
Laboratory Tests - The laboratory should provide:
Actual values for laboratory tests; and
Normal ranges of values in whether the healing narrative or attached laboratory report.
Electrocardiographic and Spirographic Reports
Tracings must be provided when these tests have been performed.
The reported findings for pulmonary and electrocardiographic studies must meet the requirements of Section 3.00E and 4.00C, respectively, of the Listing of Impairments.
Interpretation
The interpretation of laboratory tests (e.g., electrocardiographic tracings) must take into catalogue and be correlated with the history and corporal exam findings.
Identify the doctor providing the formal interpretation of the laboratory tests, when other than the doctor who is signing the Ce report.
If the interpretation is provided separately, the narrative sheet should state the interpreting physician's name and address.
X-rays
Joints and other areas to be x-rayed are those that are specifically requested or those that the corporal exam reveals to be the most complex by disease, after standard authorization by the Dds.
Rheumatology
In addition to the requirements for a general internal healing examination, the following definite facts should be stated in a narrative of an exam in which the customary complaint is a rheumatological disorder.
General Observations
General observations in the corporal exam should spin to common, everyday functions which may be observed in the examining physician's office, such as:
Stance;
Gait;
Ability to:
Dress and undress;
Climb upon the examining table;
Grasp or shake hands; and
Write.
Joint Examination
Joint exam should contain specific, detailed notations with respect to the nearnessy or absence of:
Effusion;
Episodes of infection;
Peri-articular swelling;
Tenderness;
Heat;
Redness;
Thickening of the joints;
Specific range of motion of the joints and back in degrees; and
Structural deformities.
Specific range of motion of a joint or spine should be reported in degrees for any joint or spine in which there is a needful limitation of motion.
If the range of motion is found to be restricted in any joint or spine, comment should be made as to probable cause (e.g., due to pain and/or influenced by observable abnormality).
Joints/spine to be x-rayed are those that are specifically requested or those that the corporal exam reveals to be the most complex by disease, after standard authorization by Dds.
For individuals alleging myalgias or other muscular complaints, evaluate the areas of muscle tenderness including tender points and trigger points. Go to Listing of Impairments - Adults: Immune principles 14.00 for more information.
Orthopedic
History
The orthopedic examination, including the lumbar and cervical spine, should spin and discuss (where appropriate):
The major or chief complaint(s) alleged as the infer for not working. The conference of the complaints must include:
A detailed historical narrative of the pertinent past history of the disease.
The claimant's statement of current complaint.
Current and past therapy for this disorder, and response to therapy, should be reported. Hospitalizations, surgical operations, and needful investigative procedures (e.g., myelography, Cat scan, Mri, Bone Scan) should be reported with the dates of the hospitalizations and consequent of the procedures.
The symptoms alleged, including a narrative of:
The character, location, and radiation of pain;
Mechanical factors which incite and relieve the pain;
Prescribed treatment, including name, dose, and frequency of any medications which are used;
The claimant's typical daily activities; and
Symptoms of weakness, other motor loss, or any sensory abnormalities.
The use of drugs or alcohol.
Other needful past illnesses, injuries, operations, particularly those intriguing the musculoskeletal system.
From whom the history was obtained and an evaluation of the reliability of the history.
Physical exam - The corporal exam narrative should contain a narrative and conference (where appropriate) of:
The claimant's general appearance and nutrition, any apparent skeletal or other musculoskeletal abnormalities.
The orthopedic and neurological findings. These should contain a narrative of:
Muscle spasms, limitation of movement of the spine given quantitatively in degrees from the vertical position when there is needful limitation in motion, straight leg raising given quantitatively in degrees from the supine position and from the sitting position, motor and sensory abnormalities, and deep tendon reflexes. Deep tendon reflexes should be described as to intensity and symmetry.
If there is no abnormality of range of motion of any affected joint on gross examination, that fact, rather than the actual degree of motion, may be reported.
Motor function quantitative. The method of quantitation must be reported. The most widely used method involves recording from 0 to 5 as a fraction with the numerator representing the claimant's operation and the denominator representing a general operation (e.g., 3/5).
To what degree motor function is inhibited by spasticity, rigidity or pain.
The definite distribution of sensory deficit or pain.
Muscle bulk. When there is asymmetry, definite estimation must be reported.
Atrophy must be reported in terms of circumferential measurements of both thighs and lower legs (or upper or lower arms) at a stated point above and below the knee or elbow given in inches or centimeters.
A definite narrative of atrophy of hand muscles may be given without measurements of atrophy but should contain measurements of grip strength.
Gait and station, including the claimant's quality to:
Tandem walk;
Walk on heels and toes;
Hop;
Bend;
Squat;
Arise from a squatting position;
Dress and undress;
Get up from a chair;
Get on the examining table; and
Cooperate during the examination.
Laboratory Tests - X-rays or other laboratory tests
The doctor providing the formal interpretation must be identified.
If the interpretation is provided on a isolate narrative form, that narrative should be attached.
Findings
The physician's exam findings must be considered on the basis of the physician's observations during the examination. (Alternative testing methods should be used to verify the objectivity of the abnormal findings, when possible; e.g., a seated straight-leg raising test in addition to a supine straight-leg raising test.) Go to Listing of Impairments - Adults: Musculoskeletal principles 1.00 for more information.
Respiratory
In addition to the requirements for a general internal healing examination, the definite facts listed below should be stated in a narrative of an exam in which the customary complaint is a respiratory disorder.
General Examination
The narrative should note and describe:
The occurrence of cough, labored breathing, use of accessory muscles of respiration, audible wheezing, pallor, cyanosis, hoarseness, clubbing of fingers, or the nearnessy of chest wall deformity. Respiratory rate should be observed and reported.
The diameter of the chest on inspiration and expiration, distention of neck veins and ankle edema.
Whether the expiratory phase of respiration is prolonged.
Breath sounds.
Diaphragmatic motion.
Presence or absence of adventitious sounds on auscultation of the chest.
The employment history, when relevant to the disease, should be reported (e.g., pneumoconiosis or exposure to corporal irritants producing respiratory symptoms.)
Dyspnea
Characteristics - Dyspnea should be described with respect to:
Dates and mode of onset;
Seasonal influence;
Influence of infection and precipitating activities;
Whether it is associated with palpitation, wheezing, chest discomfort, or hyperventilation symptoms.
Respiratory Versus Cardiac Dyspnea - Inquiry should be made to decree whether the claimant has:
A history of heart disease;
Experienced paroxysmal nocturnal dyspnea or orthopnea; and
Associated peripheral edema, hypertension, past myocardial infarction, angina, rheumatic heart disease, cardiac murmur, etc.
Episodic Disorders - The narrative should contain details as to:
Onset and precipitating factors;
Frequency and intensity;
Duration;
Mode of medicine and response; and
Description of severe respiratory attack.
Ancillary Studies
Chest X-ray, Spirometry, Diffusing Capacity of the lungs for Carbon Monoxide, and Arterial Blood Gas Studies will be requested in accordance with program criteria for the purpose of establishing the existence and extent of the disease process. Go to Listing of Impairments -Adults: Respiratory principles 3.00 for more information.
Cardiovascular
In addition to the requirements for a general internal healing examination, the following definite facts should be stated in a narrative of an exam in which the customary complaint is a cardiovascular disorder.
General exam - The narrative must:
Provide a detailed narrative of the exam of the heart, including the heart sounds and rhythm and pulses.
Describe:
Any jugular vein distention, including angle of reclining at which distention occurs;
Adventitious lung sounds;
Hepatomegaly;
Peripheral or pulmonary edema; and
Cyanosis.
Describe the impact of the chest discomfort, dyspnea or other cardiovascular symptoms on corporal activities.
Describe any drugs used (currently and in the modern past) for medicine of the cardiovascular disorder and indicate the dosage and the response to these drugs.
Note participation in a cardiac recovery program (e.g., progressive corporal activity, educational or psychological support).
Congestive Heart Failure - The history must contain a conference of:
The known factors in the development of the cardiac health (e.g., myocardial infarction, rheumatic heart disease, hypertension, and congenital or other organic heart disease).
Recurrent or persistent symptoms such as:
Fatigue;
Dyspnea;
Orthopnea; and
Anginal discomfort.
Chest hurt and Other Symptoms - The narrative should describe:
Chest hurt of myocardial ischemic origin or other symptom(s) in the claimant's own words with respect to:
Presence;
Character;
Location;
Radiation;
Frequency;
Duration;
Usual inciting factors; and
Relief.
The historical character of the chest hurt to ascertain whether:
There is a predictable garage pattern of occurrence; and
There is evidence of a modern convert in the pattern of symptoms;
Whether therapy has been prescribed and how the claimant is responding to the therapy;
Whether the hurt occurs at rest or awakens the claimant from sleep and whether it is associated to ingestion of food or movement of the upper extremities; and
The usual duration of the symptoms, especially chest discomfort, how symptoms are relieved, and the time required to acquire relief (e.g., rest or after taking definite drugs such as nitroglycerin).
Laboratory Tests
Ancillary cardiac testing, such as Ecg, exercise Stress Testing and Echocardiogram, will be requested in accordance with program criteria for the purpose of establishing the existence and extent of the disease process. Go to Listing of Impairments - Adults: Cardiovascular principles 4.00 for more information.
Neurological
Historical Source
The Dds will make arrangements to have a knowledgeable personel accompany the claimant to the examination, when prior facts indicates incompetence on the part of the claimant.
The doctor should indicate from whom the history was obtained and should evaluation reliability of history.
History - The history should contain a detailed description/discussion of:
Major or chief complaints with:
Detailed historical narrative of the disease state; and
Current complaints.
The thinking or corporal functional restrictions with definite examples.
Significant illness, injuries, or operations, particularly of the nervous system.
Current and past therapy for the disorder alleged, and any abuse or drugs or alcohol.
The family history with facts on pertinent positive abnormalities, particularly hereditary familial conditions.
Physical Examination
General - The corporal exam should supply a statement regarding the claimant's:
General appearance;
Nutrition;
Body habitus;
Head size and shape;
Any skeletal or other abnormalities such as pigmentary or texture changes of the skin or changes in hair distribution; and
Dominant hand
The gait and hub must be described in detail, including quality to:
Tandem walk;
Walk on heels and toes;
Hop;
Dress and undress;
Get up from a chair;
Get on the examining table; and
Generally cooperate during the examination.
Notation should be made of the function of the 12 cranial nerves (if the first cranial nerve is not tested, this should be noted). Lower cranial nerve function should be described in single information when dysphagia or dysarthria is a complaint.
Ocular motility and pupillary size and activity should be described even when normal. The optical acuity and optical fields by gross confrontation should be estimated, and the basis for the evaluation must be stated.
Motor function - Should be quantitated, and the method of quantitation reported. For example, if a numbering principles is used, the narrative must state which whole represents general force and which whole represents total paralysis.
The narrative must also spin to what degree motor function is inhibited by spasticity, rigidity, involuntary movements, or tremor.
Muscle bulk should be described, and when there is asymmetry, measurements should be reported.
The degree of fatigability following rapid, repetitive movements should be noted.
All modalities of sensation, including cortical, should be tested.
The method of testing should be recorded.
When sensory deficit or pain are described in a definite distribution, care should be taken to ascertain that the findings are consistent with neuroanatomical fact. Suspected non-physiological observations should be noted.
Coordination should be tested.
The quality to accomplish fine and dexterous movements of the hands should be described.
In-coordination or tremor at rest or during definite tests should be described in information and quantitated.
Note: Examples should be given describing the functional loss that occurs because of these events.
Reflexes
Deep tendon reflexes should be described as to intensity and symmetry.
Superficial reflexes should be described when gift and noted when absent.
Any pathological reflexes must be described in detail.
Any impairment of speech or language should be described in information with a conference of how much quality the claimant retains and how the doctor considered this. The narrative should discuss:
Aphasia;
Dysarthria;
Stuttering (fluency);
Involuntary vocalizations;
Whether speech is intelligible.
Mental Status exam - should be reported and be wide when thinking capacity is in question. The doctor should provide:
Examples of responses in testing orientation, memory, calculation, insight, general understanding, and fund of knowledge; and
A detailed narrative of mood and behavior during the examination, and any needful abnormalities. Go to Listing of Impairments - Adult: Neurological 11.00 for more information.
Mental Disorders
The psychiatric or psychological exam narrative should show not only the claimant's signs, symptoms, laboratory findings (psychological test results), and diagnosis, but also spin the consequent of the emotional or thinking disorder on the claimant's quality to function at the usual and customary level of adjustment - personal, social and occupational.
General Observations - contain in the Ce narrative general observations of:
How the claimant came to the examination:
Alone or accompanied;
Distance and mode of transportation; and
If by automobile, who drove.
General appearance:
Dress; and
Grooming
Attitude and degree of cooperation.
Posture and gait.
General motor behavior, including any involuntary movements.
Informant
The psychiatrist or psychologist should identify the man providing the history (usually the claimant) and should supply an evaluation of the reliability of the history.
Chief Complaint
This usually will consist of the claimant's allegations regarding any thinking and/or corporal problems.
History of gift Illness
This should contain a detailed chronological catalogue of the onset and progression of the claimant's current mental/emotional health with special reference to:
Date and circumstances of onset of the condition;
Date the claimant reported that the health began to interfere with work, and how it interfered;
Date the claimant reported inability to work because of the health and the circumstances;
Attempts to return to work and the results;
Outpatient evaluations and medicine for mental/emotional problems including:
Names of treating sources;
Dates of treatment;
Types of medicine (names and dosages of medications, if prescribed); and
Response to treatment.
Hospitalizations for thinking disorders including:
Names of hospitals;
Dates; and
Treatment and response.
Information regarding the claimant's:
Activities of daily living;
Social functioning;
Ability to unblemished tasks timely and appropriately; and
Episodes of decompensation and their resulting effects.
Past History should contain a longitudinal catalogue of the claimant's personal life including:
Relevant educational, medical, social, legal, military, marital, and occupational data and any associated problems in adjustment;
Details (dates, places, etc.) of any past history of inpatient medicine and hospitalizations for mental/emotional problems; and
History, if any, of substance abuse, and/or medicine in detoxification and recovery centers.
Mental Status
The personel case facts will decree the definite areas of thinking status that need to be emphasized during the examination, but ordinarily the narrative should contain a detailed narrative of the claimant's:
Appearance, behavior, and speech (if not already described);
Thought process (e.g., loosening of associations);
Thought article (e.g., delusions);
Perceptual abnormalities (e.g., hallucinations);
Mood and affect (e.g., depression, mania);
Sensorium and cognition (e.g., orientation, recall, memory, concentration, fund of information, and intelligence);
Judgment and insight; and
Capability (i.e., is the personel capable of handling awarded benefits responsibly?)
Diagnosis
American Psychiatric connection standard nomenclature as set forth in the current "Diagnostic and Statistical hand-operated of thinking Disorders."
Prognosis
Prognosis and recommendations for treatment, if indicated; also, recommendations for any other healing evaluation (e.g., neurological, general physical), if indicated.
Additional Requirements by thinking Disorder
Schizophrenic, Delusional (Paranoid) Schizo-Affective, and other Psychotic Disorders - The narrative should reflect:
Periods of abode in structured settings such as half-way houses and group homes;
Frequency and duration of episodes of illness and periods of remission; and
Side effects of medications.
Organic thinking Disorders - The narrative should reflect:
The source of the disorder, if known, the prognosis; and
Whether there is an acute or persisting process;
Whether garage or progressive; and
Changes at varied points in time.
The results of any psychological or neuropsychological testing that could serve to supplementary document an organic process and its severity.
Information regarding the results of any neurological evaluations.
Information about any neurological testing (e.g., Eeg, Ct scan) that may have been performed and the results, if available.
In thinking Retardation cases, the narrative should reflect:
Current documentation of Iq by a standardized, well-recognized measure. standard instruments will have a representative normative sample, a mean of practically 100 and standard deviation of practically 15 in the general population, and cover a broad range of cognitive and perceptual-motor functions (e.g., the Wechsler scales);
Verbal Iq, operation Iq, and full scale Iq scores, together with the personel subtest scores;
Interpretation of the scores and evaluation of the validity of the obtained scores, indicating any factors that may have influenced the results such as the claimant's attitude and degree of cooperation, the nearnessy of visual, hearing or other corporal problems, and modern prior exposure to the same or similar test; and
Consistency of the obtained test results with the claimant's education, vocational background, and social adjustment, especially in the area of personal self-sufficiency.
group security Disability healing Consultations - How to Build Your Case
