If the evidence from your doctor sources of the applicant are not sufficient to determine whether he or she is disabled, additional medical information, contact the source of the re-treatment for further information or clarification, or you agree to be searched for the EC. The source of the treatment is the preferred source for investigations related to the treatment when the source is qualified and willing to perform the examination or further evidence on the payment of fees and is generallyprovides comprehensive and timely reports. Even if only one additional test is required, treatment of source is usually the preferred source for this service. SSA regulations provide for the use of an independent source (other than the treating source) for a CE or diagnostic study if: not the source of treatment you want to carry on the investigation, there are conflicts or contradictions in the file, not by the return to the source of treatment can be solved, the plaintiff takes a different source and has a goodReason to do so, or experience indicates that the source of the treatment may be a productive source. The nature of the investigation and / or test (s) purchased will depend on the specific test for the additional markup required. If a test of equipment (eg X-ray or EKG PFS) will provide the necessary additional evidence for the award, the DDS is not required or authorized by a more comprehensive examination. If the assessment indicates that further tests can be justified, the provider mustContact DDS for approval before carrying out such tests. The prices for the EC of any state and may vary from state to state. Each state agency is responsible for supervising the overall management of the EC program.
Selecting a source of audit
DDS purchases only consultative examinations by qualified medical sources. The medical source may be the individual physician or psychologist or some other source. In the case of a child, the medical sourcemay be a pediatrician.
For "qualified" means that the medical source must be currently licensed in the state and ask to perform a training and experience to the type of examination or test. In addition, must not be prevented, the medical source from participation in our programs. The medical source must also be the necessary equipment to provide an adequate assessment and record the existence and severity of the alleged disability of a person.
Medical professionalsCEs must conduct a thorough understanding of SSA disability programs and needs tests. The physician or psychologist can either use support staff to perform the test counseling. The employees, the support (for example, X-ray technician, nurse, etc.) must meet appropriate licensing or certification requirements of the state.
In general, the sources after the date of availability, distance from home of an actor and his ability to select certainExaminations and tests.
Consultative Examination Report Content
The audit report must claim the number of applicants and a physical description of the applicant to ensure that the person is the actor.
The detail and format for reporting the results of the clinical history, physical examination, laboratory tests and discussion of results should follow the standard reporting principles for a complete medical examination.
TheReport should be complete enough to have an independent auditor on the type, severity and duration of the impairment and in adults, the applicant's ability to perform basic work functions determined. The history and physical examination must be submitted as a story of the discovery are available.
Conclusions in the report must be consistent with the results of the objective results from a clinical investigation of the applicant and symptoms, laboratory tests and showed response to treatment andall available information, including the history. The report, for adults, should include a description on the results of the provider, the ability of the individual, basic work related activities does not occur. It should contain an opinion as to whether the applicant is disabled under the meaning of the Act.
Signature Requirements
All reports must be personally reviewed and signed by the EC provider who actually carried out investigation. Providers have the test orTesting is solely responsible for the content of the report and "provided, conclusions or explanations comments. The signature of the source on a report annotated" not waterproof "or" dictated but not read is "unacceptable. A signature stamp or signature of another person registered as a nurse or secretary, is not acceptable.
Since the DDS Advisory reviews the audit reports
The DDS is required to report to the EC contribution, to determine whether certain informationInquiry was set up.
The EC report must:
Provide evidence that as a sufficient basis for decision making in relation to disability impairment it is assessed.
Be consistent. They are all diseases, disabilities and disorders described in the history are adequately assessed and reported in clinical outcomes?
The results correlate with the clinical history, physical examination and laboratory tests, and explain all the anomalies?
Berequested in accordance with other available information in the specialty of the examination.
Perhaps the report does not mention an important or relevant complaint within that specialty, which is known in other elements of the file (eg, blindness in one eye, amputations, pain, alcoholism, depression)?
Reasonable by the standards established in medical education.
Be signed.
If the report is insufficient or incomplete, contact the DDSthe provider and ask the provider for the missing information or prepare a revised report.
Elements of a comprehensive examination
A complete CE is one that is all elements of a standard examination in the specialty of the medical case. If the report of a complete CE is involved, should the report include the following elements:
Chief complaint or the director of the applicant (s);
Detailed description, in area of ??specialty testingthe history of the main application (s);
Description and layout, detailed results of the relevant "positive" and "negative" to history, examination and laboratory tests in connection with the main complaint (s) is based, and abnormalities or lack thereof reported or found during the examination or laboratory testing;
The results of laboratory and other tests (eg X) in accordance with the requirements of the DDS implemented.
Diagnosis and prognosis forImpairment of the plaintiff (s);
Statement of what the actors do not, despite his disability (ies), if the claim is based on the blindness of the law. This statement should describe the opinion of the consultant physician or psychologist about the applicant's ability, despite their impairment (s), for work related activities such as sitting, standing, walking, lifting, carrying, handling objects to do the "listening, speaking and travel, and in cases of mental disability (ies)Opinion of the physician or psychologist to understand the individual's ability to carry out and remember instructions, and respond appropriately to supervision, coworkers and work pressures in a work environment, and
The doctor or psychologist will consider, counseling, and provide an explanation or comment, the applicant's main accounts complaint (s) and other abnormalities found during the history and examination or reported by laboratory tests. History,Testing is the evaluation of the results of laboratory tests, and the conclusions, the information from the physician or psychologist who made the report available to sign.
Report Content specific value
Internal medicine
The detail and format for reporting the results of medical history, physical examination, laboratory tests and discussion of results should follow the standard reporting principles for a complete medical examination within.
SourceHistory
The doctor must state from which the history was obtained, and should give an estimate of the reliability of the story.
History of present illness
The major complaint (s), suspect the reason for not working should be discussed in detail, including:
Factors that increase the problem or impairment (s);
How long the problem has been;
Can gain factors and alleviating
The applicant must describe how the impairment (s) boundariesthe ability to function.
Relevant descriptive statements of the applicant, such as a description of chest pain should, in the words of the applicant are captured.
The information must be in a narrative, instead of "questionnaire" format or "check-off".
History of other diseases should describe previous injuries, surgeries or hospitalizations and give the dates of these events.
The current drug should be listed by the name of the drug and the dose.
Review of systems shouldto describe and discuss:
Other diseases and symptoms, the claimant has experienced in regard to specific organ systems and
The results relevant to negative, in making a differential diagnosis of the disease could be under way or in assessing the severity of the disability will be considered.
Social history, relevant information on the use of tobacco, alcohol, nonprescription drugs, etc.
The family history should be presented whenrelevant.
Signs
Vital functions should include:
Blood pressure;
Pulse rate;
Respiratory rate and
Size and weight, without shoes.
The physical examination should include a description of the general behavior of the applicant and relevant aspect in the examination (such as the right back, as the applicant or on foot, he got up from a chair, and got in and out of the cot).
This description should be in narrative, rather than"Questionnaire" or "check-off".
The report should detail the current issues of managing large and small, and particularly describing the applicant's complaints, both positive and negative, and relevant findings.
Pelvic exams should not be allowed if not explicitly.
Specific range of motion in degrees for a community should the joints, where it will be a considerable limitation of movement is reported.
NOTE: If a municipality is notabnormal mobility of the gross examination, that fact will be stated rather than reporting the degree of movement.
Laboratory tests ? The laboratory should:
The actual values ??for the laboratory analysis and
Normal range is given in the physician or laboratory report.
Reports and electrocardiographic Spiro Graphic
To provide paths when these tests have been carried out.
The reported results for lung andElectrocardiographic studies must meet the requirements of ? 4.00C and 3.00E respectively the list of impairments.
Interpretation
The interpretation of laboratory tests (eg ECG) should reflect and be correlated with the history and physical examination findings.
Identify the physician, the formal interpretation of laboratory tests, if different from the doctor, the report provides the EC signed.
If 'Interpretation will be provided separately, the paper report, enter the name of the doctor, and interprets address.
X-ray
X-raying joints and other areas are those that are specifically required or what the physical examination shows that the most affected by the disease, once approved by the DDS.
Rheumatology
In addition to the general requirements for internal medical examination, the following information should be specified in aReport on an investigation in which the complaint is a primary rheumatologic disease.
General notes
General remarks on physical examination should focus on the everyday functions that can be observed in the study of the medical examiner, such as focus:
Stance;
Gait;
Ability:
Dressing and undressing;
Climb up on the couch;
Grab or shake hands, and
Writing.
Joint examination
Joint investigation shouldcertain spellings as the presence or absence of detailed:
Effusion;
Consequences of infection;
Periarticular swelling;
Tenderness;
Heat;
Redness;
Thickening of the joints;
Specific mobility in the joints and spine in degrees and
Structural deformities.
Mobility of a specific joint or joints of the spine must be in degrees for each joint or the spine, where there is a significant limitation of movement are reported.
If 'Range of motion is limited in each community or the spine, is the entry to be made as a probable cause (for example due to pain and / or influenced by observable anomalies).
Joints / spine X-rays are those that are specifically required or what the physical examination shows that the most affected by the disease, once approved by DDS.
For people who complained of muscle pain or other musculoskeletal diseases, evaluate the areas of muscle tenderness, includingtender points and trigger points. Go to the List of Impairments ? Adults: Immune system 14,00 for further information.
Orthopedic
History
The orthopedic examination, including cervical and lumbar spine should describe and discuss (if applicable):
The principal or chief complaint (s), suspect the reason for not working. The discussion of the complaint must contain:
A detailed history of each of the past illness.
TheStatement of protest over the actor.
The past and current treatment for this condition, and response to therapy should be reported. Hospital stays, surgeries, and significant research methods (eg myelography, CT, MRI, bone scan) should be consistent with the recording date and the outcome of proceedings to be reported.
The alleged symptoms, including a description of:
The character, location and radiation of pain;
Mechanical factors fueling,and alleviate pain;
Prescribed treatment, including name, dose and frequency of all medications that are used;
Typical activities of the plaintiff and newspaper
The symptoms of weakness, loss of motor or sensory disorders.
The use of drugs or alcohol.
Other diseases of the past, accidents, surgeries, especially those involving the musculoskeletal system.
Of which preserve the history and an estimate of the reliability ofHistory.
Physical examination ? Physical examination report should include a description and discussion (if applicable):
General appearance of the applicant and nutrition, all the apparent anomalies and other skeletal muscle.
The orthopedic and neurological problems. This should include a description of:
Muscle spasms, restriction of movement of the spine given quantitatively in degrees from the vertical when there is no significant limitationMovement, lifting the leg straight as quantitatively in degrees from the supine position and sitting position, the motor and sensory disorders and tendon reflexes. Tendon reflexes, the intensity and symmetry are considered.
If there are deviations of range of motion of each municipality in a superficial analysis of this fact, but interesting as the actual amount of exercise, can be reported.
Motor function quantitatively. The method of quantification must be reported. Themost commonly used method involves the collection as a break with the 0-5 counter, the performance of the applicant and the denominator is a normal return (for example, 5.3).
To what degree of motor function is inhibited by spasticity, stiffness or pain.
The distribution of specific sensory deficits or pain.
Muscle mass. If an asymmetry, the measurement must be specifically reported.
Atrophy should be reported both in terms of measuring the extentThighs and legs (or arms up or down) specified at a point above and below the knee or elbow in inches or centimeters.
A detailed description of the atrophy of the muscles of the hand can be given without measures of atrophy but should include measures of grip strength.
Gait and station, including the applicant's ability to:
Tandem walk;
Walking on heels and toes;
Hops;
Bend;
Squat;
Arise from a squatting position;
Dress andUndressing;
Rising from a chair;
Get on the couch, and
Cooperate with the audit.
Laboratory tests ? X-ray or other laboratory
The physician provides the interpretation to be formally identified.
If the interpretation is provided with a separate module, the report must be attached.
Results
Medical examination results are to be determined on the basis of observations of the physician during the examination.(. Alternative test methods must be used to ensure the objectivity of the abnormal results, if possible, for example, a chair leg raising test in addition to check into a supine leg raising test) to the list of impairments Go ? Adults: Musculoskeletal 1.00 for more information.
Respiratory
In addition to the general requirements for internal medical examination, which must be given specific information listed on a study in which the primary in a reportComplaint is a respiratory illness.
General examination
The report should note and describe:
The onset of coughing, wheezing, use of accessory respiratory muscles, audible wheezing, pallor, cyanosis, hoarseness, clubbing of fingers, or the presence of chest wall deformity. Respiratory rate must be monitored and reported.
The diameter of the chest in inspiration and expiration, stretching the neck veins and ankle edema.
If the expiratory phaseProlonged breathing.
Breath sounds.
Diaphragmatic movement.
Presence or absence of contaminants on auscultation.
The history of work should, where appropriate, the disease will be reported (eg, silicosis or exposure to physical stimuli, producing respiratory symptoms.)
Dyspnea
Features ? shortness of breath should be described in relation to:
Dates and mode of onset;
Flu;
Influence of infections andFailures activities;
If it is connected with heart palpitations, shortness of breath, chest pain or symptoms of hyperventilation.
Cardiac dyspnea respiratory Versus ? investigation should be done to determine whether the applicant:
A history of heart disease;
Expert orthopnea or paroxysmal nocturnal dyspnea and
Associated peripheral edema, high blood pressure, past heart attack, angina pectoris, rheumatic heart disease, heart murmur, etc.
Episodic disturbances ? L 'Report should contain:
Onset and precipitating factors;
Frequency and intensity;
Duration;
Methods of handling and response and
Description of severe respiratory attacks.
Studies accessories
Chest X-ray, spirometry, diffusing capacity of lung for carbon monoxide and arterial blood gas studies are needed according to the criteria of the program to establish the existence and extent of the disease. ToList of Impairments-adults: Respiratory System 3.00 for more information.
Cardiovascular-
In addition to the general requirements for internal medical examination, the following information in a report on an investigation in which the complaint is a primary cardiovascular diseases are detected.
General Examination ? The report must:
Enter a detailed examination of the heart, between the sounds and rhythms andImpulses.
Describe:
A relaxation of the carotid artery, including relaxing reclining angle in which it occurs;
Accidental lung sounds;
Hepatomegaly;
Peripheral edema or pulmonary and
Cyanosis.
Describe the effects of chest discomfort, shortness of breath or other cardiovascular symptoms during physical activity.
Describe all drugs (now or in the recent past) for the treatment of cardiovascular disease and show the dose and the response tothese drugs.
Note that participation in a cardiac rehabilitation program (such as progressive physical activity, educational support and psychological).
Heart failure ? The story should have a discussion:
Other known factors for the development of heart disease (eg myocardial infarction, rheumatic heart disease, hypertension and congenital heart defects or other biological).
Recurrent or persistent symptoms such assuch as:
Fatigue;
Dyspnea;
And orthopnea
Discomfort angina.
Chest discomfort and other symptoms ? The report should describe:
Chest pain or other symptoms of ischemic stroke (s) with the words of the applicant in relation to:
Presence;
Characters;
Position;
Radiation protection;
Frequency;
Duration;
Normally, inciting factors and
Relief.
The historical character of the pain in the chest to assesswhen:
It is a stable, predictable pattern of occurrence and
There is evidence of a recent change in the pattern of symptoms;
If therapy was prescribed and how the actor is responding to therapy;
If symptoms occur at rest, or wakes from sleep, and if the applicant is linked to the ingestion of food or the movement of the upper limbs and
The normal duration of symptoms, especially chest pain, as the symptoms areincreased and the time taken to obtain relief (eg rest or after taking certain medications such as nitroglycerin).
Laboratory tests
Auxiliary heart tests such as ECG, echocardiogram and stress test is based on program criteria may be required to determine the existence and extent of the disease. Go to the List of Impairments ? Adults: The Cardiovascular System 4.00 for more information.
Neurological
HistoricallySource
The DDS will make arrangements to accompany a competent person of the applicant for the verification, if and when the first information indicates incompetence on the part of the applicant.
The doctor must state from which the history was obtained, and must assess the reliability of the story.
History ? The history should include a detailed description / discussion are:
Principal or chief complaints:
Detailed historical description of the disease state;and
Complaints in progress.
The mental or physical functional limitations with concrete examples.
Major illnesses, injuries or operations, particularly the nervous system.
The past and current treatment for the disease and the alleged abuse or drug or alcohol.
The history of the family with relevant information about positive anomalies, hereditary conditions very familiar.
Test
General ? The physical examination shouldDeclaration by the applicant:
General appearance;
Nutrition;
Habitus;
Head size and shape;
Any skeletal or other abnormalities such as pigmentary changes or texture of the skin or hair changes in the distribution and
Dominant Hand
The pace and the station must be described in detail, including the ability to:
Tandem walk;
Walking on heels and toes;
Hops;
Dressing and undressing;
Rising from a chair;
Get on the couch;and
To cooperate in general during the investigation.
Notation, the function of the 12 cranial nerves (if the first cranial nerve is not tested and it should be noted) are done. The lower cranial nerve function should be specified in detail when dysphagia or dysarthria is a failure.
Ocular and pupil size and activity should be described even in normal. Visual acuity and fields should be by comparing the estimated gross, and the basis forEstimates indicate.
Motor function ? to quantify, and report the method of quantification. For example, if a numbering system used, the report is the number that represents the normal force and that the number represents a total paralysis.
The report should also describe the degree of motor function by spasticity, rigidity, involuntary movements or convulsions will be inhibited.
Muscle mass should be described, and if it must asymmetry, the measurementsreported.
The degree of fatigue after a rapid, repetitive movements should be considered.
All modes of sensation, including cortical, must be tested.
The test method should be registered.
If sensory loss or pain in a particular distribution are described, you should make sure that the results are consistent with neuroanatomical reality. Suspicion of non-physiological observations should be considered.
Coordination should be tested.
TheMust do ability, fine motor and dexterous hands are described.
In coordination or tremor at rest or in certain tests must be described in detail and quantified.
Note: These should describe as the functional loss that occurs as a result of these events.
Reflections
Tendon reflexes, the intensity and symmetry are considered.
To describe skin reflexes, if available, noting if his absence.
Any pathologicalReflexes should be described in detail.
Any impairment of speech and language should be in the detail with a discussion of what the applicant's ability and how you keep the doctor determines they are described. The report should discuss:
Aphasia;
Dysarthria;
Stuttering (fluency);
Involuntary sounds;
This speech is understandable.
Mental status ? must be reported and expanded when the mental faculties may be called into question. The physician should: supply
Examples of orientation response tests, memory, calculation, knowledge, general understanding, and the fund of knowledge and
A detailed description of the mood and behavior during the investigation, and any significant anomalies. Go to the List of Impairments ? Adults: neurological 11.00 for more information.
Mental Disorders
The report psychiatric or psychological examination to show not only the applicant signs, symptoms, laboratory values ??(psychologicalTest results), and the diagnosis, but also the effect of emotional disturbances or mental incapacity of the applicant to operate a normal and customary to describe control ? personal, social and professional.
General comments ? in the EC report general observations:
As an actor, came to the test:
Alone or in company;
Distance and transport;
If travel by car.
General appearance:
Dress;and
Grooming
Attitude and the degree of cooperation.
Posture and gait.
General behavior of the engine, including any involuntary movements.
Informant
The psychiatrist or psychologist should be the person who provides the story (usually the applicant) and give an estimate of the reliability of the story.
Chief Complaint
This rule will consist of statements of the applicant on any mental health problems and / or physical.
HistoryDisease present
This should include a detailed chronological account of the genesis and progression of existing disease, mental / emotional, with particular reference to the applicant:
Date and circumstances of the outbreak of the disease;
Date on which the applicant has reported that the condition interfere with the work started, and how they intervene;
Given the impossibility plaintiff reported to work because of the conditions and circumstances;
Trying to work again andResults;
Outpatient assessment and treatment of mental / emotional problems, including:
The name of the handling of sources;
Dates of treatment;
Types of treatment (names and dosages of medications if prescribed), and
The response to treatment.
Hospital admissions for mental disorders, including:
The names of the hospitals;
Dates and
And treatment response.
Information from the applicant:
Activities of daily living;
SocialOperation;
The ability to complete tasks quickly and appropriately, and
Episodes of heart failure and the resulting effects.
The history of the past should be a longitudinal account of the applicant's personal life, including:
Relevant educational, medical, social, legal, information, military, marriage and career and all the associated problems of adjustment;
Details (dates, locations, etc.) from any past, ambulatory care and hospitalization for mental / emotionalProblems and
The story, possibly, drug abuse and / or treatment centers, detoxification and rehabilitation.
State of Mind
The individual case facts determine the specific areas of mental status that need to be highlighted during the investigation, but in general the report should include a detailed description of the applicant:
Appearance, behavior and language (if not already described);
The thought process (eg, loosening of associations);
ThinkContent (eg delusions);
Perceptual abnormalities (eg, hallucinations);
Mood and affect (eg depression, mania);
Sensorium and cognition (eg, orientation, memory, memory, concentration, background information and intelligence);
Judgement and understanding, and
Capacity (eg, the individual is able to manage services in a responsible manner as well?)
Diagnosis
American Psychiatric Association's standard nomenclature, that the current "Diagnostic andStatistical Manual of Mental Disorders. "
Forecast
The prognosis and treatment recommendations, if given further advice on any medical evaluation (eg, neurological, general physical condition), if indicated.
Additional requirements of mental disorders
Schizophrenic, delusional (paranoid), schizo-affective and other psychotic disorders ? The report should reflect:
Residence in structured environments, such as halfway houses and groupHouses;
Frequency and duration of episodes of illness and periods of remission and
Side effects of medications.
Organic mental disorders ? the report should reflect:
The source of the problem, if known, the prognosis and
If there is an acute or chronic process;
Stable or progressive and
The changes at different points in time.
The results of neuropsychological and psychological tests that can be used to further document a staffProcess and its severity.
Information on the results of the neurological assessments.
Information on the neurological tests (eg, EEG, CT scans), who have performed and the results, if available.
In cases of mental retardation, the report should reflect:
Current documentation of the IQ of a standard to measure well recognized. Tools have an acceptable legal representative sample, on average about 100 and a standard deviation ofabout 15 in the general population, and cover a wide range of cognitive and perceptual-motor functions (eg, Wechsler Scales);
Verbal IQ, performance IQ and full-scale IQ, along with the individual subtest scores;
The interpretation of the results and assess the validity of the vote could be indicating any factors that influenced the results, as have the attitude of the applicant and the degree of cooperation, the presence of visual, auditory or otherphysical problems, and recent exposure before the test or the like, and
The consistency of test results with the applicant on the education and professional background and get the social adjustment, particularly in the personal independence.
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