Consultative Examinations: A Guide for Health Professionals

Part V - Pediatric Consultative Examination Report Content Guidelines

The following are guidelines for minimum content requirements for CE reports on Pediatric claimants. Each DDS will notify medical sources of any additional requirements.

General Pediatric Consultative Examination and Report

General Guidelines
The report must be complete enough to help the DDS adjudicative team determine the medical severity and duration of the impairment(s), the type(s) of treatment and extra care required in the management of the impairment(s), and functional limitations related to the impairment(s).

  1. General
    1. Identify claimant
      1. Include the claimant’s claim number, and
      2. Indicate that the claimant provided proof of identity by showing an original document proving U.S. citizenship, age and identity (social security card, U.S. passport, birth certificate, student or school ID, daycare center or school record), and
      3. Provide a physical description of the claimant, to help ensure that the person being examined is the claimant.
    2. Medical Records/History Documentation
      1. Cite the medical records and any other documents reviewed prior to or during the course of the evaluation. Medical records provided by the DDS should be listed. A statement should be made if no medical documents were provided for review by the DDS.
      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 – Describe/discuss as appropriate:
    1. The child’s impairment(s) for which the SSI 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)
    6. Source(s) of medical care including specialist(s) or specialty clinic(s)

  3. Past Medical History – Describe/discuss as appropriate:
    1. Prenatal, delivery, and neonatal course
    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 where treatment was given.  

  4. Review of Systems – Describe/discuss other signs/symptoms and pertinent negative findings of the child relevant to the specific impairment(s) being evaluated and not otherwise described above in current medical history.
     
  5. Growth and Development – Describe/discuss as appropriate:
    1. Any delay in length/height or weight growth when impairment(s) would be expected to affect growth
    2. Developmental milestones if under age 6. The results of a formalized developmental screening test can meet this requirement.
    3. Early infant or preschool intervention services
    4. For children 6 and older, usual daily activities
    5. Current grade, type of class, limitations of activities or need for special assistance or extra care
       
  6. Social History – Describe/discuss, as appropriate, based on the child’s age, pertinent findings about use of tobacco products, alcohol, non-prescription drugs, etc.
     
  7. Family History – Describe/discuss family composition, health of family members, similar disease/disorder in other members of the family, the primary caretaker(s) and their role in providing for the child’s medical and daily activity needs.

  8. Physical Examination – The report should present aspects of the examination dealing with the child’s condition(s)/impairment(s) and describe both pertinent positive and negative findings. The report should include:
    1. Length/Height and weight measurements and percentiles based on the most recent CDC growth standards
    2. Blood pressure, pulse rate and rhythm, respiratory rate, if appropriate
    3. General appearance including any obvious vision or hearing problems, facial, skeletal or other abnormalities, as appropriate
    4. Description of the interaction with examiner and ability to understand directions and communicate clearly with content appropriate for age
    5. General pediatric exam and body specific examination, as appropriate
  1. Interpretation of laboratory tests results (If the interpretation is provided separately, the report sheet should state the interpreting medical source’s name and address)
    1. Identify the medical source (name and address) providing the formal interpretation of the laboratory tests when that source is other than the individual signing the CE report.
    2. Provide interpretation of laboratory results that takes into account, and correlates with, the history and physical examination findings.

  2. Diagnosis, prognosis, and clinical assessment based on history, observations made during the physical examination, and results of relevant laboratory test(s). The statement should include a description of any limitation(s) in abilities/activities, which result from the condition(s)/impairment(s) evaluated.

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Report Content by Specific Impairment

Pediatric - Growth  

(Boldface type indicates requirements not found in the General Pediatric Report)

General Guidelines
The report must be complete enough to help the DDS adjudicative team determine the medical severity and duration of the impairment(s), the type(s) of treatment and extra care required in the management of the impairment(s), and functional limitations related to the impairment(s).

  1. General
    1. Identify Claimant
      1. Include the claimant’s claim number, and
      2. Indicate that the claimant provided proof of identity by showing an original document proving U.S. citizenship, age and identity (social security card, U.S. passport, birth certificate, student or school ID, daycare center or school record), and
      3. Provide a physical description of the claimant, to help ensure that the person being examined is the claimant.
    2. Medical Record/History Documentation
      1. Cite the medical records and any other documents reviewed prior to or during the course of the evaluation. Medical records provided by the DDS should be listed. A statement should be made if no medical documents were provided for review by the DDS.
      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 – Describe/discuss as appropriate:
    1. The child’s medical impairment that is a known to be a cause of linear growth impairment
    2. Onset and duration of the medical and linear growth impairments
    3. Current treatment plan including medicines and dosages, role of child and caretaker 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)
    6. Source(s) of medical care including specialist(s) or specialty clinic(s)
    7. Recording of the adult heights of the child’s natural parents

  3. Past Medical History – Describe/discuss as appropriate:
    1. Prenatal, delivery, and neonatal course
    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 where treatment was given.  

  4. Review of Systems – Describe/discuss other signs/symptoms and pertinent negative findings of the child relevant to the specific impairment(s) being evaluated and not otherwise described above in current medical history.

  5. Growth and Development – Describe/discuss as appropriate
    1. Developmental milestones if under age 6.  The results of a formalized developmental screening test can meet this requirement
    2. Early infant or preschool intervention services
    3. For children 6 and older, usual daily activities
    4. Current grade, type of class, limitations of activities or need for special assistance

  6. Social History – Describe/discuss, as appropriate, based on the child’s age, pertinent findings about use of tobacco products, alcohol, non-prescription drugs, etc.

  7. Family History – Describe/discuss family composition, health of family members, similar disease/disorder in other members of family, the primary caretaker(s) and their role in providing for the child’s medical and daily activity needs.

  8. Physical Examination – The report should present aspects of the examination dealing  with the child’s condition(s)/impairment(s) and describe both pertinent positive and negative findings. The report should include:
    1. Length/Height and weight measurements and percentiles based on the most recent CDC growth standards
    2. Blood pressure, pulse, respiratory rate, if appropriate
    3. General appearance including any obvious vision or hearing problems, facial, skeletal or other abnormalities
    4. Description of the interaction with examiner and ability to understand directions and communicate clearly with content appropriate for age
    5. General pediatric exam

  9. Interpretation of laboratory tests results when ordered by the DDS or otherwise available from medical records (e.g., tests to establish the severity of the disorder that is causally related to the linear growth impairment (see body system specific tests); and, bone age).
    1. Identify the name and address of the medical source providing the formal interpretation of the laboratory tests when that source is other than individual signing the CE report.
    2. Provide an interpretation of laboratory results that takes into account, and correlates with, the history and physical examination findings.

  10. Diagnosis, prognosis, and clinical assessment based on history, observations made during the physical examination, and results of relevant laboratory test(s) including the following:
    1. A statement indicating whether the child’s linear growth delay or short stature may be the result of familial short stature, constitutional growth delay (CGD), or due to a causative medically determinable impairment.
    2. A rationale for whatever conclusion reached by the CE provider regarding the child’s growth delay or short stature
    3. Recommendations for medical evidence needed to confirm CGD when not otherwise available to the CE provider (e.g., bone age determination)

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Pediatric - Musculoskeletal System

(Boldface type indicates requirements not found in the General Pediatric Report)

General Guidelines
The report must be complete enough to help the DDS adjudicative team determine the medical severity and duration of the impairment(s), the type(s) of treatment and extra care required in the management of the impairment(s), and functional limitations related to the impairment(s).

  1. General
    1. Identify Claimant
      1. Include the claimant’s claim number, and
      2. Indicate that the claimant provided proof of identity by showing an original document proving U.S. citizenship, age and identity (social security card, U.S. passport, birth certificate, student or school ID, daycare center or school record), and
      3. Provide a physical description of the claimant, to help ensure that the person being examined is the claimant.
    2. Medical Records/History Documentation
      1. Cite the medical records and any other documents reviewed prior to or during the course of the evaluation. Medical records provided by the DDS should be listed. A statement should be made if no medical documents were provided for review by the DDS.
      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 – Describe/discuss as appropriate:
    1. The child’s impairment(s) for which the SSI disability claim is being filed
    2. Onset and duration of the impairment(s)
    3. Treatments including casting, surgery, medicines and dosages, or special therapy/home exercises and frequency
    4. Use of orthosis, prosthesis, walker, hand held assistive device, or wheelchair 
    5. Response to treatment and overall amelioration of the impairment(s)
    6. Source(s) of medical/surgical care including hospital, specialist(s) or specialty clinic(s) with dates of service, when possible  
    7. Unmet medical/surgical care needs

  3. Past Medical History – Describe/discuss as appropriate:
    1. Prenatal, delivery, and neonatal course
    2. Other significant events including past illnesses, injuries, operations,hospitalizations, and emergency department encounters. When possible provide the dates of events and names of facilities where treatment was given.  

  4. Review of Systems – Describe/discuss other signs/symptoms and pertinent negative findings of the child relevant to the specific impairment(s) being evaluated and not otherwise described above in current medical history.

  5. Growth and Development – Describe/discuss as appropriate:
    1. Any growth delay when impairment(s) would be expected to affect growth
    2. Developmental milestones if under age 6. The results of a formalized developmental screening test can meet this requirement.
    3. Early infant or preschool intervention services
    4. For children 6 and older, usual daily activities
    5. Current grade, type of class, limitations of activities or need for specialassistance or extra care

  6. Social History – Describe/discuss, as appropriate, based on the child’s age, pertinentfindings about use of tobacco products, alcohol, non-prescription drugs, etc.

  7. Family History – Describe/discuss family composition, health of family members, similar disease/disorder in other members of the family, the primary caretaker(s) and their role in providing for the child’s medical and daily activity needs.

  8. Physical Examination – The report should present aspects of the examination dealing with the child’s condition(s)/impairment(s) and describe both pertinent positive and negative findings. The report should include:
    1. Length/Height and weight measurements and percentiles based on the most recent CDC growth standards
    2. Blood pressure, pulse, respiratory rate, if appropriate
    3. General appearance including any obvious vision or hearing problems, facial,  skeletal or other abnormalities
    4. Description of the interaction with examiner and ability to understand directions and communicate clearly with content appropriate for age
    5. Exam to include:
      1. Gait, station, ability to ambulate, and perform upper extremity fine and  gross motor movements.
      2. Quality of movements and presence of extraneous movements
      3. Spine deformity including scoliosis or kyphosis
      4. Joint abnormality, active and passive movement, and range of motion
      5. Limb deficiency including amputation and description of stump and skin flap integrity
      6. Need for and ability to use orthotic or prosthetic device or wheelchair

  9. Interpretation of laboratory tests results when ordered by the DDS or otherwise available from medical records (e.g., imaging studies (x ray, CT, MRI); electrodiagnostic procedures (electromyography, nerve conduction); and, gene and biochemical testing).
    1. Identify the name and address of the medical source providing the formal interpretation of the laboratory tests when that source is other than the individual signing the CE report.
    2. Provide an interpretation of laboratory results that takes into account, and correlates with, the history and physical examination findings. 

  10. Diagnosis, prognosis, and clinical assessment based on history, observations made during the physical examination, and results of relevant laboratory test(s). The statement should include a description of the specific limitation(s) abilities/activities which result from the condition(s)/impairment(s) evaluated.

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Pediatric - Special Senses and Speech

   Visual Impairments

   (Boldface type indicates requirements not found in the General Pediatric Report)

General Guidelines
The report must be complete enough to help the DDS adjudicative team determine the medical severity and duration of the impairment(s), the type(s) of treatment and extra care required in the management of the impairment(s), and functional limitations related to the impairment(s).

  1. General
    1. Identify Claimant
      1. Include the claimant’s claim number, and
      2. Indicate  that the claimant provided proof of identity by showing an original document proving U.S. citizenship, age and identity (social security card, U.S. passport, birth certificate, student or school ID, daycare center or school record), and
      3. Provide a physical description of the claimant, to help ensure that the person being examined is the claimant. 
    2. Medical Records/History Documentation
      1. Cite the medical records and any other documents reviewed prior to or during the course of the evaluation. Medical records provided by the DDS should be listed. A statement should be made if no medical documents were provided for review by the DDS.
      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 – Describe/discuss as appropriate:
    1. The visual loss and how it affects the claimant
    2. Onset and duration of the impairment(s)
    3. Current treatment plan including medicines and dosages, role of child and caretaker in administration of treatment plan, need for periodic adjustments in medication regimen, special therapy, equipment or devices
    4. Response to treatment and overall extent of control of the impairment(s)
    5. Source(s) of medical care including specialist(s) or specialty clinic(s)
    6. Unmet medical care needs

  3. Past Medical History – Describe/discuss as appropriate:
    1. Prenatal, delivery, and neonatal course
    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 where treatment was given.

  4. Review of Systems – Describe/discuss other signs/symptoms and pertinent negative   findings of the child relevant to the specific impairment(s) being evaluated and not otherwise described in current medical history.

  5. Social History – Describe/discuss, as appropriate, based on the child’s age, pertinent findings about use of tobacco products, alcohol, non-prescription drugs, etc.

  6. Growth and Development – Describe/discuss as appropriate
    1. Any delay in length/height or weight growth when impairment(s) would be expected to affect growth
    2. Developmental milestones if under age 6. The results of a formalized developmental screening test can meet this requirement
    3. Early infant or preschool intervention services
    4. For children age 6 and older, usual daily activities
    5. Current grade, type of class, limitations of activities or need for special assistance

  7. Family History – Describe/discuss family composition, health of family members, similar or genetic eye  disease/disorder in other  members of the family, the primary caretaker(s) and their role in providing for the child’s medical and daily activity needs.

  8. Physical Examination – The report should present aspects of the examination dealing with the child’s condition(s)/impairment(s) and describe both pertinent positive and negative findings. The report should include a complete visual exam:
    1. Description of the interaction with examiner and ability to understand directions and communicate clearly with content appropriate for age
    2. Best corrected central visual acuity as follows:
      1. For preverbal children: precise evaluation of child’s fixation and following behavior and whether central, steady, and maintained
      2. Preschool verbal children: evaluation with Snellen test (evaluation with Allen cards, Tumbling E, or HOTV test if unable to recognize Snellen chart)
    3. Confrontation visual fields
    4. Pupillary exam
    5. External exam
    6. Exam of anterior segment (iris, anterior chamber, cornea, lenses)
    7. Adnexa (orbit, lacrimal gland, lids)
    8. Intraocular pressure
    9. Muscle balance
    10. Optic nerve evaluation (CID ration)
    11. Retinal exam (macula, vessels, periphery)
    12. Humphrey Field Analyzer (HFA) Visual Fields (if indicated)
      1. HFA 30-2
      2. HFA 24-2

  9. Laboratory and other tests results when ordered by the DDS or otherwise available from medical records.  Information on this report should include:
    1. The name and address of the medical source providing the formal interpretation of the laboratory tests when that source is other than the individual signing the CE report.
    2. An interpretation of all laboratory results that takes into account, and correlates with, the history and physical examination findings.

  10. Diagnosis, prognosis, and clinical assessment based on history, observations made during the physical examination, and results of relevant laboratory test(s). The statement should include a description of any limitation(s) in abilities/activities, which result from the condition(s)/impairment(s) evaluated.

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   Hearing Impairments

   (Boldface type indicates requirements not found in the General Pediatric Report)

General Guidelines
The report must be complete enough to help the DDS adjudicative team determine the medical severity and duration of the impairment(s), the type(s) of treatment and extra care required in the management of the impairment(s), and functional limitations related to the impairment(s).

  1. General
    1. Identify Claimant
      1. Include the claimant’s claim number, and
      2. Indicate that the claimant provided proof of identity by showing an original document proving U.S. citizenship, age and identity (social security card, U.S. passport, birth certificate, student or school ID, daycare center or school record), and
      3. Provide a physical description of the claimant, to help ensure that the person being examined is the claimant. 
    2. Medical Records/History Documentation
      1. Cite the medical records and any other documents reviewed prior to or during the course of the evaluation. Medical records provided by the DDS should be listed.  A statement should be made if no medical documents were provided for review by the DDS.
      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 – Describe/discuss as appropriate:
    1. The hearing loss and how it affects the claimant
    2. Onset and duration of the impairment(s)
    3. Current treatment plan including medicines and dosages, role of child and caretaker in administration of treatment plan, need for periodic adjustments in medication regimen, special therapy, equipment or devices
    4. Response to treatment and overall extent of control of the impairment(s)
    5. Source(s) of medical care including specialist(s) or specialty clinic(s)

  3. Past Medical History – Describe/discuss as appropriate:
    1. Prenatal, delivery, and neonatal course
    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 where treatment was given.

  4. Review of Systems – Describe/discuss other signs/symptoms and pertinent negative findings of the child relevant to the specific impairment(s) being evaluated and not otherwise described above in current medical history.

  5. Growth and Development – Describe/discuss as appropriate:
    1. Any delay in length/height or weight growth when impairment(s) would be expected to affect growth
    2. Developmental milestones if under age 6. The results of a formalized developmental screening test can meet this requirement.
    3. Early infant or preschool intervention services
    4. For children 6 and older, usual daily activities
    5. Current grade, type of class, limitations of activities or need for special assistance or extra care

  6. Social History – Describe/discuss, as appropriate, based on the child’s age, pertinent findings about use of tobacco products, alcohol, non-prescription drugs, etc.

  7. Family History – Describe/discuss family composition, health of family members, similar disease/disorder in other  members of the family, the primary caretaker(s) and their role in providing for the child’s medical and daily activity needs.

  8. Physical Examination – The report should present aspects of the examination dealing with the child’s condition(s)/impairment(s) and describe both pertinent positive and negative findings. The report should include a complete hearing exam
    1. Description of the interaction with examiner and ability to understand directions and communicate clearly with content appropriate for age, estimate of speech intelligibility when first spoken, and if appropriate, after repetition
    2. Description of the appearance of external ears (pinnae and external ear canals)
    3. Evaluation of the tympanic membranes and assessment of any middle ear abnormalities

  9. Laboratory and other tests results when ordered by the DDS or otherwise available from medical records (examples include):
    1. Audiometric testing appropriate for age
    2. Children from birth to age 6 months:   tone specific brainstem response (ABR)
    3. Children from 6 months to age 2 years: air conduction thresholds determined by a behavioral assessment, usually visual reinforcement audiometry (VRA). Results of ABR can be used if behavioral assessment cannot be completed of if results are incomplete or unreliable. Testing in sound field is acceptable
    4. Children from age 2 to age 5 years: air conduction thresholds determined by a behavior assessment, such as conditioned play audiometry (CPA), tangible or visually reinforced operant conditioning audiometry (TROCA, VROCA, or VRA) Results of ABR can be used if behavioral assessment cannot be completed or if results are incomplete or unreliable. Testing in sound field is acceptable
    5. Children from age 5 to age 18 years: pure tone air conduction and bone conduction testing, speech reception threshold (SRT) testing and word/speech recognition/discrimination testing each ear separately
    6. Children from age 5 to age 18 years, with cochlear implant(s):  HINT testing in quiet, in sound field with cochlear implant in place and functioning properly or an equivalent audiometric test 

    Information on this report should include:

    1. The name and address of the medical source providing the formal interpretation of the laboratory tests when that source is other than the individual signing the CE report.
    2. An interpretation of all laboratory results that takes into account, and correlates with, the history and physical examination findings.

  10. Diagnosis, prognosis, and clinical assessment based on history, observations made during the physical examination, and results of relevant laboratory test(s).  The statement should include a description of any limitation(s) in abilities/activities which result from the condition(s)/impairment(s) evaluated.

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Pediatric - Respiratory System

(Boldface type indicates requirements not found in the General Pediatric Report)

General Guidelines
The report must be complete enough to help the DDS adjudicative team determine the medical severity and duration of the impairment(s), the type(s) of treatment and extra care required in the management of the impairment(s), and functional limitations related to the impairment(s).

  1. General
    1. Identify Claimant
      1. Include the claimant’s claim number, and
      2. Indicate that the claimant provided proof of identity by showing an original document proving U.S. citizenship, age and identity (social security card, U.S. passport, birth certificate, student or school ID, daycare center or school record), and
      3. Provide a physical description of the claimant, to help ensure that the person being examined is the claimant. 
    2. Medical Record/History Documentation
      1. Cite the medical records and any other documents reviewed prior to or during the course of the evaluation.  Medical records provided by the DDS should be listed.  A statement should be made if no medical documents were provided for review by the DDS.
      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 – Describe/discuss as appropriate:
    1. The child’s impairment(s) for which the SSI disability claim is being filed
    2. Onset, frequency of episodes, and duration of the impairment(s) as experienced during the day or night on a weekly or monthly basis
    3. Current treatment plan including medicines and dosages, role of child and caretaker in administration of treatment plan, need for periodic adjustments in medication regimen (including oxygen), special therapy and amount, equipment or devices
    4. Response to treatment and overall control of the impairment(s)
    5. Source(s) of medical care including specialist(s) or specialty clinic(s), indicating their role in treatment and frequency seen in the past 12 months
    6. Hospitalization(s) and emergency department care for respiratory impairment(s) with names of facilities and dates when possible

  3. Past Medical History – Describe/discuss as appropriate
    1. Prenatal, delivery, and neonatal course
    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 where treatment was given.

  4. Review of Systems – Describe/Discuss other signs/symptoms and pertinent negative findings of the child relative to the specific impairment(s) being evaluated and not otherwise described in current medical history.

  5. Growth and Development – Describe/Discuss as appropriate:
    1. Any delay in length/height or weight growth when impairment(s) would be expected to affect growth
    2. Developmental milestones if under age 6. The results of a formalized developmental screening test can meet this requirement
    3. Early infant or preschool intervention services
    4. For children 6 and older, usual daily activities
    5. Current grade, type of class, limitation of activities or need for special assistance or extra care

  6. Social History – Describe/discuss, as appropriate, based on the child’s age, pertinent findings about use of tobacco products, alcohol, non-prescription drugs, etc.

  7. Family History – Describe/discuss family composition, health of family members, similar disease/disorder in other members of the family, the primary caretaker(s), and their role in providing for the child’s medical and daily activity needs.

  8. Physical Examination – The report should present aspects of the examination dealing with the child’s condition(s)/impairment(s) and describe both pertinent positive and negative findings. The report should include:
    1. Length/height and weight measurements and percentiles based on the most current CDC growth standards
    2. Blood pressure, pulse, respiratory rate
    3. General appearance during the exam including pallor, cyanosis, clubbing, nutritional status
    4. Description of the interaction with examiner and ability to understand directions and communicate clearly with content appropriate for age
    5. Exam to include:
      1. Chest wall abnormality, labored breathing, audible wheezing, cough
      2. Abnormal auscultation findings
      3. Presence of tracheostomy, oxygen need, G-tube, central venous line

  9. Interpretation of -laboratory and other tests ordered by the DDS or otherwise available from medical records (examples include):
    1. Pulmonary function testing
    2. Arterial blood gas studies (studies are not purchased by the Social Security Administration)
    3. Pulse oximetry
    4. Imaging studies (studies are not purchased by the Social Security Administration)

    Information on the CE report should include:

    1. The name and address of the medical source providing the formal interpretation of the laboratory tests when that source is other than the individual signing the CE report
    2. An interpretation of all laboratory results that takes into account, and correlates with, the history and physical examination findings.

  10. Diagnosis, prognosis, and clinical assessment based on history, observations made  during the physical examination, and results of relevant laboratory test(s). The statement should include a description of any limitation(s) in abilities/activities which result from the condition(s)/impairment(s) evaluated.

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Pediatric - Cardiovascular System

(Boldface type indicates requirements not found in the General Pediatric Report)

General Guidelines
The report must be complete enough to help the DDS adjudicative team determine the medical severity and duration of the impairment(s), the type(s) of treatment and extra care required in the management of the impairment(s), and functional limitations related to the impairment(s).

  1. General
    1. Identify Claimant
      1. Include the claimant’s claim number, and
      2. Indicate that the claimant provided proof of identity by showing an original document proving U.S. citizenship, age and identity (social security card, U.S. passport, birth certificate, student or school ID, daycare center or school record), and
      3. Provide a physical description of the claimant, to help ensure that the person being examined is the claimant.
    2. Medical Records/History Documentation
      1. Cite the medical records and any other documents reviewed prior to or during the course of the evaluation. Medical records provided by the DDS should be listed. A statement should be made if no medical documents were provided for review by the DDS.
      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 – Describe/discuss as appropriate:
    1. The child’s impairment(s) for which the SSI disability claim is being filed
    2. Onset, frequency, and duration of the impairment(s)
    3. Dyspnea, orthopnea, exercise intolerance, hypercyanotic spells, slow feeding, squatting, syncope
    4. Poor weight or length/height growth
    5. Current treatment plan including medicines and dosages, role of child and caregiver in administration of treatment plan, need for periodic adjustments in medication regimen
    6. Special therapy, equipment or devices
    7. Response to treatment and overall extent of control of the impairment(s)
    8. Source(s) of medical care including specialist(s) or specialty clinic(s)

  3. Past Medical History – Describe/discuss as appropriate:
    1. Prenatal, delivery, and neonatal course
    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 where treatment was given.  

  4. Review of Systems – Describe/discuss other signs/symptoms and pertinent negative findings of the child relevant to the specific impairment(s) being evaluated and not otherwise described in current medical history.

  5. Growth and Development – Describe/discuss as appropriate:
    1. Any growth delay when impairment(s) would be expected to affect growth
    2. Developmental milestones if under age 6. The results of a formalized developmental screening test can meet this requirement.
    3. Early infant or preschool intervention services
    4. For children 6 and older, usual daily activities
    5. Current grade, type of class, limitations of activities or need for special assistance or extra care

  6. Social History – Describe/discuss, as appropriate, based on the child’s age, pertinent findings about use of tobacco products, alcohol, non-prescription drugs, etc.

  7. Family History – Describe/discuss family composition, health of family members, similar disease/disorder in other members of family, the primary caretaker(s) and their role in providing for the child’s medical and daily activity needs.

  8. Physical Examination – The report should present aspects of the examination dealing with the child’s condition(s)/impairment(s) and describe, as appropriate, both pertinent positive and negative findings:
    1. Length/Height and weight measurements and percentiles based on the most recent CDC growth standards
    2. Blood pressure (upper and lower extremities), peripheral pulses, pulse rate and rhythm, respiratory rate and effort
    3. Obvious vision or hearing problems, facial, skeletal or other abnormalities
    4. Description of the interaction with examiner and ability to understand directions and communicate clearly with content appropriate for age
    5. Exam to include:
      1. Evidence of cyanosis (perioral, peripheral), pallor, clubbing
      2. Heart sounds, murmurs
      3. Presence of hepatomegaly or edema

  9. Interpretation of laboratory and other test results when ordered and authorized by the DDS or otherwise available from medical records (examples include):
    1. EKGs
    2. Imaging studies
    3. Pulse oximetry
    4. ECHO

    Information on this report should include:

    1. The name and address of the medical source providing the formal interpretation of the laboratory tests when that source is other than the individual signing the CE report.
    2. An interpretation of all laboratory results that takes into account, and correlates with, the history and physical examination findings.

  10. Diagnosis, prognosis, and clinical assessment based on history, observations made during the physical examination, and results of relevant laboratory test(s). The statement should include a description of any limitation(s) in abilities/activities which result from the condition(s)/impairment(s) evaluated.

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Pediatric - Digestive System

(Boldface type indicates requirements not found in the General Pediatric Report)

General Guidelines
The report must be complete enough to help the DDS adjudicative team determine the medical severity and duration of the impairment(s), the type(s) of treatment and extra care required in the management of the impairment(s), and functional limitations related to the impairment(s).

  1. General
    1. Identify Claimant
      1. Include the claimant’s claim number, and
      2. Indicate that the claimant provided proof of identity by showing an original document proving U.S. citizenship, age and identity (social security card, U.S. passport, birth certificate, student or school ID, daycare center or school record) and,
      3. Provide a physical description of the claimant, to help ensure that the person being examined is the claimant. 
    2. Medical Records/History Documentation
      1. Cite the medical records and any other documents reviewed prior to or during the course of the evaluation. Medical records provided by the DDS should be listed.  A statement should be made if no medical documents were provided for review by the DDS.
      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 – Describe/discuss as appropriate:
    1. The child’s impairment(s) for which the SSI disability claim is being filed
    2. Onset and duration of the impairment(s)
    3. Ascites, biliary disease, blood transfusion, peritonitis, bowel obstruction, perineal disease, gastrostomy, short bowel syndrome, enteral nutrition 
    4. Poor weight or length/height growth
    5. Current treatment plan including medicines and dosages, role of child and caretaker in administration of treatment plan, need for periodic adjustments in medication regimen, special therapy, equipment or devices
    6. Response to treatment and overall extent of control of the impairment(s)
    7. Source(s) of medical care including specialist(s) or specialty clinic(s)

  3. Past Medical History – Describe/discuss as appropriate:
    1. Prenatal, delivery, and neonatal course
    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 where treatment was given.

  4. Review of Systems – Describe/discuss other signs/symptoms and pertinent negative findings of the child relevant to the specific impairment(s) being evaluated and not otherwise described above in current history.

  5. Growth and Development – Describe/discuss as appropriate:
    1. Any growth delay when impairment(s) would be expected to affect growth
    2. Developmental milestones if under age 6. The results of a formalized developmental screening test can meet this requirement.
    3. Early infant or preschool intervention services
    4. For children 6 and older, usual daily activities
    5. Current grade, type of class, limitations of activities or need for special assistance or extra care

  6. Social History – Describe/discuss, as appropriate, based on the child’s age, pertinent findings about use of tobacco products, alcohol, non-prescription drugs, etc.

  7. Family History – Describe/discuss family composition, health of family members, similar disease/disorder in other members of the family, the primary caretaker(s) and their role in providing for the child’s medical and daily activity needs.

  8. Physical Examination – The report should present aspects of the examination dealing with the child’s condition(s)/impairment(s) and describe both pertinent positive and negative findings. The report should include:
    1. Length/Height, weight, and weight for length/height or BMI measurements and percentiles based on the most recent CDC growth standards
    2. Blood pressure, pulse, respiratory rate, if appropriate
    3. General appearance including presence of jaundice or pallor, nutritional status
    4. Obvious vision or hearing problems, facial, skeletal or other abnormalities
    5. Description of the interaction with examiner and ability to understand directions and communicate clearly with content appropriate for age
    6. Exam to include: 
      1. Liver and spleen size,
      2. Presence of edema, acites, asterixis
      3. Evidence of perineal disease
      4. Rectal exam, as appropriate

  9. Interpretation of laboratory/other tests when ordered and authorized by the DDS or otherwise available from medical records (examples include):
      1. Hemoglobin
      2. Serum creatinine
      3. Serum albumin
      4. Liver function studies
      5. INR
      6. Liver biopsy or cholangiogram

      Information on this report should include:

    1. The name and address of the medical source providing the formal interpretation of the laboratory tests when that source is other than the individual signing the CE report.
    2. An interpretation of laboratory results that takes into account, and correlates with, the history and physical examination findings.

  10. Diagnosis, prognosis, and clinical assessment based on history, observations made during the physical examination, and results of relevant laboratory test(s). The statement should include a description of any limitation(s) in abilities/activities which result from the condition(s)/impairment(s) evaluated.

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Pediatric - Genitourinary Impairments

(Boldface type indicates requirements not found in the General Report)

General Guidelines
The report must be complete enough to help the DDS adjudicative team determine the medical severity and duration of the impairment(s), the type(s) of treatment and extra care required in the management of the impairment(s), and functional limitations related to the impairment(s).

  1. General
    1. Identify Claimant
      1. Include the claimant’s claim number, and
      2. Indicate that the claimant provided proof of identity by showing an original document proving U.S. citizenship, age and identity (social security card, U.S. passport, birth certificate, student or school ID, daycare center or school record), and
      3. Provide a physical description of the claimant, to help ensure that the person being examined is the claimant.
    2. Medical Records/History Documentation
      1. Cite the medical records and any other documents reviewed during the course of the evaluation. Medical records provided by the DDS should be listed.  A statement should be provided if no medical documents were made available for review by the DDS.
      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 – Describe/discuss as appropriate:
    1. The child’s impairment(s) for which the SSI disability claim is being filed
    2. Onset and duration of the impairment(s)
    3. Malaise, fatigue, poor appetite/weight gain or loss, edema, headache, bone pain
    4. Current treatment plan including medicines and dosages, role of child and caretaker in administration of treatment plan, need for periodic adjustments in medication regimen, special therapy, equipment or devices
    5. Response to treatment and overall extent of control of the impairment(s)
    6. Source(s) of medical care including specialist(s) or specialty clinic(s)

  3. Past Medical History – Describe/discuss as appropriate:
    1. Prenatal, delivery, and neonatal course
    2. Other significant events including prior renal dialysis, past illnesses, urinary tract infections, injuries, operations, hospitalizations, and urgent care encounters. When possible provide the dates of events and names of facilities where treatment was given.  

  4. Review of Systems – Describe/discuss other signs/symptoms and pertinent negative findings of the child relevant to the specific impairment(s) being evaluated and not otherwise described above in current medical history.

  5. Growth and Development – Describe/discuss as appropriate:
    1. Any growth delay when impairment(s) would be expected to affect growth
    2. Developmental milestones if under age 6. The results of a formalized developmental screening test can meet this requirement.
    3. Early infant or preschool intervention services
    4. For children 6 and older, usual daily activities
    5. Current grade, type of class, limitation of activities or need for special assistance or extra care

  6. Social History – Describe/discuss, as appropriate, based on the child’s age, pertinent findings about use of tobacco products, alcohol, non-prescription drugs, etc.

  7. Family History – Describe/discuss family composition, health of family members, and the primary caretaker(s) and their role in providing for the child’s medical and daily activity needs.

  8. Physical Examination – The report should present aspects of the examination dealing with the child’s condition(s)/impairment(s) and describe both pertinent positive and negative findings. The report should include:
    1. Length/Height and weight measurements and percentiles based on the most recent CDC growth standards
    2. Blood pressure, pulse, respiratory rate and rhythm
    3. General appearance including any pallor, obvious vision or hearing problems, facial, skeletal or other abnormalities, as appropriate
    4. Description of the interaction with examiner and ability to understand directions and communicate clearly with content appropriate for age
    5. Exam to include:
      1. Fundoscopic and any retinal change
      2. Abdominal swelling, masses, genital abnormalities
      3. Presence of edema
      4. Rachitic changes
      5. Neurological findings (irritability, hypotonia)

  9. Laboratory and other tests when authorized and ordered by the DDS or otherwise available from medical records  Information on this report should include:
    1. The name and address of the medical source providing the formal interpretation of laboratory or other tests when that source is other than the individual signing the CE report.
    2. An interpretation by the CE provider of all laboratory results that takes into account, and correlates with, the history and physical examination findings.

  10. Diagnosis, prognosis, and clinical assessment based on history, observations made during the physical examination, and results of relevant laboratory test(s). The statement should include a description of any limitation(s) in abilities/activities which result from the condition(s)/impairment(s) evaluated.

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Pediatric - Hematological Disorders

(Boldface type indicates requirements not found in the General Report)

General Guidelines
The report must be complete enough to help the DDS adjudicative team determine the medical severity and duration of the impairment(s), the type(s) of treatment and extra care required in the management of the impairment(s), and functional limitations related to the impairment(s).

  1. General
    1. Identify Claimant
      1. Include the claimant’s claim number, and
      2. Indicate tha the claimant provided proof of identity by showing an original document proving U.S. citizenship, age and identity (social security card, U.S. passport, birth certificate, student or school ID, daycare center or school record), and
      3. Provide a physical description of the claimant, to help ensure that that the person being examined is the claimant.
    2. Medical Records/History Documentation
      1. Cite the medical records and any other documents reviewed prior to or during the  course of the evaluation. Medical records provided by the DDS should be listed. A statement should be made if no medical documents were provided for review by the DDS.
      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 – Describe/discuss as appropriate:
    1. The child’s impairment(s) for which the SSI disability claim is being filed
    2. Onset, frequency of episodes, severity, and duration of the impairment(s)
    3. Fatigue/anorexia, pain crisis, headaches, weight loss/gain, edema, pallor, or jaundice ,
    4. Bleeding diathesis (ecchymoses, gum bleeding), transfusions (RBC, platelets, plasma factors) and frequency of events
    5. Visceral episodes (acute chest, CVA,  osteomyelitis)
    6. Current treatment plan including medicines and dosages, role of child and caretaker in administration of treatment plan, need for periodic adjustments in medication regimen, special therapy, equipment or devices
    7. Response to treatment and overall extent of control of the impairment(s)
    8. Source(s) of medical care including specialist(s) or specialty clinic(s)

  3. Past Medical History – Describe/discuss as appropriate:
    1. Prenatal, delivery, and neonatal course
    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 where treatment was given.

  4. Review of Systems – Describe/discuss other signs/symptoms and pertinent negative findings of the child relevant to the specific impairment(s) being evaluated and not otherwise described above in current medical history.

  5. Growth and Development – Describe/discuss as appropriate:
    1. Any growth delay when impairment(s) would be expected to affect growth
    2. Developmental milestones if under age 6.  The results of a formalized developmental screening test can meet this requirement
    3. Early infant or preschool intervention services
    4. For children 6 and older, usual daily activities expected for age and any problems or limitations of activities or need for special assistance or extra care  
    5. Current grade, type of class, limitations of activities or need for special assistance or extra care

  6. Social History – Describe/discuss, as appropriate, based on the child’s age, pertinent findings about use of tobacco products, alcohol, non-prescription drugs, etc.

  7. Family History – Describe/discuss family composition, health of family members, similar disease/disorder in other members of family, the primary caretaker(s) and their role in providing for the child’s medical and daily activity needs.

  8. Physical Examination – The report should present aspects of the examination dealing with the child’s condition(s)/impairment(s) and describe both pertinent positive and negative findings.  The report should include:
    1. Length/Height and weight measurements and percentiles based on the most recent CDC growth standards
    2. Blood pressure, pulse, respiratory rate, if appropriate
    3. General appearance including any pallor, scleral icterus or jaundice
    4. Description of the interaction with examiner and ability to understand directions and communicate clearly with content appropriate for age
    5. Exam to include:
      1. Evidence of bleeding (ecchymoses, petechiae, hemarthrosis)
      2. Liver and spleen size
      3. Evidence of hemarthrosis
      4. Abnormal neurological findings

  9. Interpretation of laboratory and other tests when authorized and ordered by the DDS or otherwise available from medical records. Examples include:
    1. Hemoglobin electrophoresis
    2. Hemoglobin/Hematocrit and reticulocyte values
    3. Clotting factor assays
    4. Imaging studies (chest x-ray, CT, MRI, TCD)
  10. Information on this report should include:

    1. The name and address of the medical source providing the formal interpretation of the laboratory tests when that source is other than the individual signing the CE report.
    2. An interpretation of all laboratory results that takes into account, and correlates with, the history and physical examination findings.

  11. Diagnosis, prognosis, and clinical assessment based on history, observations made during the physical examination, and results of relevant laboratory test(s). The statement should include a description of any limitation(s) in abilities/activities which result from the condition(s)/impairment(s) evaluated.

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Pediatric - Skin Disorders

(Boldface type indicates requirements not found in the General Report)

General Guidelines
The report must be complete enough to help the DDS adjudicative team determine the medical severity and duration of the impairment(s), the type(s) of treatment and extra care required in the management of the impairment(s), and functional limitations related to the impairment(s).

  1. General
    1. Identify Claimant
      1. Include the claimant’s claim number, and
      2. Indicate that the claimant provided proof of identity by showing an original document proving U.S. citizenship, age and identity (social security card, U.S. passport, birth certificate, student or school ID, daycare center or school record), and
      3. Provide a physical description of the claimant, to help ensure that the person being examined is the claimant.
    2. Medical Records/History Documentation
      1. Cite the medical records and any other documents reviewed prior to or during the course of the evaluation. Medical records provided by the DDS should be listed.  A statement should be provided if no medical documents were made available for review by the DDS.
      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 – Describe/discuss as appropriate:
    1. The child’s impairment(s) for which the SSI disability claim is being filed
    2. Onset, frequency of flare ups, and duration of the impairment(s)
    3. Environmental influences on the disorder (e.g., allergens, irritants, light) 
    4. Pain, pruritus
    5. Loss of function and limitation of motion
    6. Emotional/social impact of the disorder
    7. Current treatment plan including medicines and dosages, role of child and care taker in administration of treatment plan, need for periodic adjustments in medication regimen, special therapy, equipment or devices
    8. Response to treatment and overall extent of control of the impairment(s)
    9. Source(s) of medical care including specialist(s) or specialty clinic(s)

  3. Past Medical History – Describe/discuss as appropriate:
    1. Prenatal, delivery, and neonatal course
    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 where treatment was given.  

  4. Review of Systems – Describe/discuss other signs/symptoms and pertinent negative findings of the child relevant to the specific impairment(s) being evaluated and not otherwise described in current medical history.

  5. Growth and Development – Describe/discuss as appropriate:
    1. Any growth delay when impairment(s) would be expected to affect growth
    2. Developmental milestones if under age 6. The results of a formalized developmental screening test can meet this requirement.
    3. Early infant or preschool intervention services
    4. For children 6 and older, usual daily activities
    5. Current grade, type of class, limitations of activities or need for special assistance

  6. Social History – Describe/discuss, as appropriate, based on the child’s age, pertinent findings about use of tobacco products, alcohol, non-prescription drugs, etc.

  7. Family History – Describe/discuss family composition, health of family members, and the primary caretaker(s) and their role in providing for the child’s medical and daily activity needs.

  8. Physical Examination – The report should present aspects of the examination dealing with the child’s condition(s)/impairment(s) and describe both pertinent positive and negative findings. The report should include:
    1. Length/Height and weight measurements and percentiles based on the most recent CDC growth standards
    2. Blood pressure, pulse, respiratory rate, if appropriate
    3. General appearance including any obvious vision or hearing problems, facial, skeletal or other abnormalities, as appropriate
    4. Description of the interaction with examiner and ability to understand directions and communicate clearly with content appropriate for age
    5. Exam to include:
      1. Description of extent and location of the skin lesions
      2. Disfigurement or deformity of affected area
      3. Range of motion of affected joints.  

  9. Laboratory and other tests when authorized and ordered by the DDS or otherwise available from medical records.
  10. Information on this report should include:

    1. The name and address of the medical source providing the formal interpretation of the laboratory tests when that source is other than the individual signing the CE report.
    2. An interpretation of all laboratory results that takes into account, and correlates with, the history and physical examination findings.

  11. Diagnosis, prognosis, and clinical assessment based on history, observations made during the physical examination, and results of relevant laboratory test(s). The statement should include a description of any limitation(s) in abilities/activities which result from the condition(s)/impairment(s) evaluated.

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Pediatric - Endocrine Disorders

(Boldface type indicates requirements not found in the General Report)

General Guidelines
The report must be complete enough to help the DDS adjudicative team determine the medical severity and duration of the impairment(s), the type(s) of treatment and extra care required in the management of the impairment(s), and functional limitations related to the impairment(s).

  1. General
    1. Identify Claimant
      1. Include the claimant’s claim number, and
      2. Indicate that the claimant provided proof of identity by showing an original document proving U.S. citizenship, age and identity (social security card, U.S. passport, birth certificate, student or school ID, daycare center or school record), and
      3. Provide a physical description of the claimant, to help ensure that the person being examined is the claimant. 
    2. Medical Records/History Documentation
      1. Cite the medical records and any other documents reviewed during the course of the evaluation. Medical records provided by the DDS should be listed.  A statement should be provided if no medical documents were made available for review by the DDS.
      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 – Describe/discuss as appropriate:
    1. The child’s impairment(s) for which the SSI disability claim is being filed including the following:
      1. Changes in growth pattern (recent weight loss/gain or  increase/decrease in appetite)
      2. Visual disorder
      3. Heat or cold intolerance
      4. Changes in elimination patterns (constipation, diarrhea, urinary frequency)
      5. Bone pain
      6. Neurologic or behavioral changes (seizures, cramps, paresthesias, tremors, emotional lability)
      7. Metabolic disturbances (hyperglycemia, hypoglycemia, acidosis)
      8. Changes in hair texture or distribution.
    2. Onset and duration of the impairment(s)
    3. Current treatment plan including medicines and dosages, role of child and adult caretaker in administration of treatment plan, need for periodic adjustments in medication regimen, special therapy, equipment or devices
    4. Response to treatment and overall extent of control of the impairment(s)
    5. Source(s) of medical care including specialist(s) or specialty clinic(s)

  3. Past Medical History – Describe/discuss as appropriate:
    1. Prenatal, delivery, and neonatal course
    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 where treatment was given.  

  4. Review of Systems – Describe/discuss other signs/symptoms and pertinent negative findings of the child relevant to the specific impairment(s) being evaluated and not otherwise described above in current medical history.

  5. Growth and Development – Describe/discuss as appropriate:
    1. Any growth delay when impairment(s) would be expected to affect growth
    2. Developmental milestones if under age 6. The results of a formalized developmental screening test can meet this requirement.
    3. Early infant or preschool intervention services
    4. For children 6 and older, usual daily activities
    5. Current grade, type of class, limitations of activities or need for special assistance or extra care

  6. Social History – Describe/discuss, as appropriate, based on the child’s age, pertinent findings about use of tobacco products, alcohol, non-prescription drugs, etc.

  7. Family History – Describe/discuss family composition, health of family members similar disease/disorder in other members of family, the primary caretaker(s) and their role in providing for the child’s medical and daily activity needs.

  8. Physical Examination – The report should present aspects of the examination dealing with the child’s condition(s)/impairment(s) and describe both pertinent positive and negative findings. The report should include:
    1. Length/Height and weight measurements and percentiles based on the most recent CDC growth standards
    2. Blood pressure, pulse rate and rhythm, respiratory rate, if appropriate
    3. General appearance including any obvious vision or hearing problems, facial, skeletal or other abnormalities
    4. Description of the interaction with examiner and ability to understand directions and communicate clearly with content appropriate for age
    5. Exam to include:
      1. Skin/hair color/texture changes, sweating
      2. Eye changes (exophthalmus, visual fields, EOM)
      3. Presence/absence of goiter
      4. Presence/absence of abdominal mass
      5. Assessment of reflex activity and muscle strength
      6. Presence/absence of tremulousness, Trousseau or Chvostek signs.
      7. Mental status

  9. Laboratory and other tests when authorized and ordered by the DDS or otherwise available from medical records.
  10. Information on this report should include:

    1. The name and address of the medical source providing the formal interpretation of laboratory or other tests when that source is other than the individual signing the CE report.
    2. An interpretation by the CE provider of all laboratory results that takes into account, and correlates with, the history and physical examination findings. 

  11. Diagnosis, prognosis, and clinical assessment based on history, observations made during the physical examination, and results of relevant laboratory test(s). The statement should include a description of any limitation(s) in abilities/activities which result from the condition(s)/impairment(s) evaluated.

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Pediatric ? Multiple Body Systems

(Boldface type indicates requirements not found in the General Report)

General Guidelines
The report must be complete enough to help the DDS adjudicative team determine the medical severity and duration of the impairment(s), the type(s) of treatment and extra care required in the management of the impairment(s), and functional limitations related to the impairment(s).

  1. General
    1. Identify Claimant
      1. Include the claimant’s claim number, and
      2. Indicate that the claimant provided proof of identity by showing an original document proving U.S. citizenship, age and identity (social security card, U.S. passport, birth certificate, student or school ID, daycare center or school record), and
      3. Provide a physical description of the claimant, to help ensure that the person being examined is the claimant.
    2. Medical Records/History Documentation
      1. Cite the medical records and any other documents reviewed prior to or during the course of the evaluation. Medical records provided by the DDS should be listed.  A statement should be made if no medical documents were provided for review by the DDS.
      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 – Describe/discuss as appropriate:
    1. The child’s impairment(s) for which the SSI disability claim is being filed
    2. Onset and duration of the impairment(s)
    3. Current treatment plan including medicines and dosages, role of child and caretaker in administration of treatment plan, need for periodic adjustments in medication regimen, special therapy, equipment or devices
    4. Response to treatment and overall extent of control of the impairment(s)
    5. Source(s) of medical care including specialist(s) or specialty clinic(s)

  3. Past Medical History – Describe/discuss as appropriate:
    1. Prenatal, delivery, and neonatal course
    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 where treatment was given.

  4. Review of Systems – Describe/discuss other signs/symptoms and pertinent negative findings of the child relevant to the specific impairment(s) being evaluated and not otherwise described above in current medical history.

  5. Growth and Development – Describe/discuss as appropriate:
    1. Any delay in length/height or weight growth when impairment(s) would be expected to affect growth
    2. Developmental milestones if under age 6. The results of a formalized developmental screening test can meet this requirement.
    3. Infant or preschool intervention services
    4. For children 6 and older, usual daily activities
    5. Current grade, type of class, limitations of activities or need for special assistance

  6. Social History – Describe/discuss, as appropriate, based on the child’s age, pertinent findings about use of tobacco products, alcohol, non-prescription drugs, etc.

  7. Family History – Describe/discuss family composition, health of family members, similar disease/disorder/syndrome in other family members, the primary caretaker(s) and their role in providing for the child’s medical and daily activity needs.

  8. Physical Examination – The report should present aspects of the examination dealing with the child’s condition(s)/impairment(s) and describe both pertinent positive and negative findings. The report should include:
    1. Length/Height and weight measurements and percentiles based on the most recent CDC growth standards
    2. Blood pressure, pulse, respiratory rate, if appropriate
    3. General appearance including any obvious vision or hearing problems
    4. Clinical description of the diagnostic physical features, skeletal or other abnormalities, as appropriate
    5. Description of the interaction with examiner and ability to understand directions and communicate clearly with content appropriate for age
    6. General pediatric exam

  9. Interpretation of laboratory and other tests results when authorized and ordered by the DDS or otherwise available from medical records (examples include):
    1. Genetic studies
    2. Histopathological findings
    3. Enzyme studies
    4. Plasma and urine acid analysis
    5. Imaging studies

    Information on the CE report should include:

    1. The name and address of the medical source providing the formal interpretation of the laboratory tests when that source is other than the individual signing the CE report.
    2. An interpretation of all laboratory results that takes into account, and correlates with, the history and physical examination findings.

  10. Diagnosis, prognosis, and clinical assessment based on history, observations made  during the physical examination, and results of relevant laboratory test(s). The statement should include a description of any limitation(s) in abilities/activities which result from the condition(s)/impairment(s) evaluated.

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Pediatric - Neurological Disorders

(Boldface type indicates requirements not found in the General Report)

General Guidelines
The report must be complete enough to help the DDS adjudicative team determine the medical severity and duration of the impairment(s), the type(s) of treatment and extra care required in the management of the impairment(s), and functional limitations related to the impairment(s).

  1. General
    1. Identify Claimant
      1. Include the claimant’s claim number, and
      2. Indicate that the claimant provided proof of identity by showing an original document proving U.S. citizenship, age and identity (social security card, U.S. passport, birth certificate, student or school ID, daycare center or school record), and
      3. Provide a physical description of the claimant, to help ensure that the person being examined is the claimant. 
    2. Medical Records/History Documentation
      1. Cite the medical records and any other documents reviewed prior to or during the course of the evaluation. Medical records provided by the DDS should be listed.  A statement should be made if no medical documents were provided for review by the DDS.
      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 – Describe/discuss as appropriate:
    1. The child’s impairment(s) for which the SSI disability claim is being filed
    2. Onset and duration of the impairment(s) with clear description of how the diagnosis was initially established followed by review of the treatment/treatments administered in chronological order and the response.
    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, special therapy, equipment or devices. 
    4. Use of assistive devices or braces being used, when they are used and by whom they were prescribed (also see H.5.h.)
    5. For seizure disorder complete description to include the following:     
      1. Complete description of prodrome, aura, nature of seizure activity, duration of events, description of and duration of the postictal state, and the frequency
      2. Side effects of medications
      3. Injuries sustained due to seizures should be discussed
      4. Diagnostic studies
      5. Associated neurological problems
      6. Antiepileptic blood levels and evidence of compliance
      7. Any seizure log/calendar available -- if included, clearly state the source of this log/calendar information
    6. Response to treatment and overall extent of control of the impairment(s)
    7. Source(s) of medical care including specialist(s) or specialty clinic(s) including current prescriber of the medications. 
    8. List any special care required, e.g., special nursing care, need for bladder catheterization, special diets, special equipment, etc.

  3. Past Medical History – Describe/discuss as appropriate:
    1. Prenatal, delivery, and neonatal course
    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 where treatment was given.

  4. Review of Systems – Describe/discuss other signs/symptoms and pertinent negative   findings of the child relevant to the specific impairment(s) being evaluated and not otherwise described above in current medical history.

  5. Growth and Development – Describe/discuss as appropriate:
    1. Any delay in length/height or weight growth when impairment(s) would be expected to affect growth
    2. Developmental milestones if under age 6. The results of a formalized developmental screening test can meet this requirement
    3. Early infant or preschool intervention services
    4. For children 6 and older, usual daily activities
    5. Current grade, type of class, limitations of activities or need for special assistance

  6. Social History – Describe/discuss, as appropriate, based on the child’s age, pertinent   findings about use of tobacco products, alcohol, non-prescription drugs, etc. 

  7. Family History – Describe/discuss family composition, health of family members, similar disease/disorder in other members of family, the primary caretaker(s) and their role in providing for the child’s medical and daily activity needs. 

  8. Physical Examination – The report should present aspects of the examination dealing with the child’s condition(s)/impairment(s) and describe both pertinent positive and negative findings.  The written report should include a complete neurological examination and should not be in the form of a check list. 
    1. Length/Height, weight, head circumference measurements and percentiles based on the most recent CDC growth standards
    2. Blood pressure, pulse, respiratory rate, if appropriate
    3. General appearance including any obvious vision or hearing problems, facial, skeletal or other abnormalities, skin lesions or scars (especially if any surgical procedures are reported)
    4. Description of the interaction with examiner and ability to understand directions and communicate clearly with content appropriate for age
    5. Neurological exam to include:
      1. Mental status examination appropriate for age
      2. Hand dominance
      3. Cranial nerve evaluation
      4. Motor strength and how tested, reflexes, muscle bulk, and tone. 
      5. Abnormal movements
      6. Gait and fine motor coordination
      7. Sensation and how tested
      8. Assistive device or brace brought to examination with description and opinion regarding its medical necessity  

    Note:  When muscle strength testing for younger children is not possible, record observations of abilities such as rolling over, sitting, standing, running, climbing stairs, etc.

  9. Laboratory and other tests when authorized and ordered by the DDS or otherwise available from medical records.  Information on this report should include:
    1. The name and address of the medical source providing the formal interpretation of the laboratory tests when that source is other than the individual signing the CE report.
    2. An interpretation of laboratory results that takes into account, and correlates with, the history and physical examination findings.

  10. Diagnosis, prognosis, and clinical assessment based on history, observations made during the physical examination, and results of relevant laboratory test(s). The statement should include a description of any limitation(s) in abilities/activities which result from the condition(s)/impairment(s) evaluated.

Note:  A general conclusion regarding the child/claimant being disabled should be avoided but any specific limitations in function that can be inferred from this examination should be stated.

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Pediatric - Mental Disorders

(Boldface type indicates requirements not found in the General Report)

General Guidelines
The report must be complete enough to help the DDS adjudicative team determine the medical severity and duration of the impairment(s), the type(s) of treatment and extra care required in the management of the impairment(s), and functional limitations related to the impairment(s).

  1. General
    1. Identify Claimant
      1. Include the claimant’s claim number, and
      2. Indicate that the claimant provided proof of identity by showing an original document proving U.S. citizenship, age and identity (social security card, U.S. passport, birth certificate, student or school ID, daycare center or school record), and
      3. Provide a physical description of the claimant, to help ensure that the person being examined is the claimant. 
    2. Medical Records/History Documentation
      1. Cite the medical records and any other documents reviewed prior to or during the course of the evaluation.  All medical records reviewed, and sources, should be listed.   A statement should be made if no medical documents were made available for review by the DDS.
      2. Identify the person(s) providing the oral medical history and comment on the validity and reliability of such information.

  2. Current Medical History – Describe/discuss as appropriate:
    1. The mental impairment(s) for which the disability claim is being filed.
    2. Other observed or alleged mental impairment(s)
    3. Physical observations 
    4. Onset and duration of the impairment(s).
    5. Current treatment, including medicines and dosages, role of child and caregiver in administration of medications and treatment plan, adjustments in medication regimen, psychotherapy and behavioral interventions, IEP or other school interventions, and early infant or pre-school intervention services.  Identify treating sources, if known.
    6. Response to treatment and extent of control of the impairment(s), as described by parents/third parties, and documented in records. 

  3. Past Medical History – Describe/discuss as appropriate:
    1. Prenatal, delivery, and neonatal course
    2. Other significant events including past illnesses, injuries, operations, hospitalizations, and urgent care encounters.  When possible, include dates of events and names of facilities where treatment was given, particularly mental health treatment.

  4. Social History – Describe/discuss use of tobacco products, alcohol, non-prescription drugs, etc.

  5. Family History – Describe/discuss family composition, health of family members including similar disease/disorders in other members of family, the primary caretaker(s) and their role in providing for the child’s medical, emotional, and daily activity needs.  Include longitudinal history of relations with parents, family, peers, etc.

  6. Educational History

  7. Birth to Attainment of Age 3, Developmental Examination for Infants and ToddlersThe report should include:
    1. History of attainment of developmental milestones (sitting unsupported, standing, walking, etc…).
    2. Responsiveness to visual, auditory, and tactile stimuli (birth to 12 months).
    3. Motor Coordination (fine/gross, left/right dominant).
    4. Communicative behaviors, including pre-speech (sucking, swallowing, imitation of sounds) and early language (jargon, single words, phrases, turn taking).
    5. Manner of relating to and interacting with parent or caregiver, ability to separate from parent/caregiver.
    6. Manner of relating to and interacting with siblings or peer group, if possible to observe.
    7. Any stereotypical movements.
    8. Perceptual functioning.
    9. Other pathology/psychopathology.

  8. Mental Assessment for Children 3 – 18 years. The report should include as appropriate for age:
    1. History of adjustment in school and home, daily activities, social activities, other activities that reflect the child’s concentration and task persistence.
    2. Objective findings and observations:
      1. Appearance and grooming
      2. Behavior during exam
      3. Mood and affect
      4. Communicative abilities, speech, thought processes (with examples)
      5. Cognitive abilities, estimated or measured via objective tests, if authorized by the DDS
    3. Indications of substance abuse; indications of self-injury
    4. When testing is performed, include results of tests and description of behavior during testing (focused/distracted, compliant/resistant), and assessment of whether behavior during testing had adverse effects on results.

  9. Mental Status Examination for Children age 12 and over, and, as appropriate, for children under 12 years. The report should include:
    1. Assessment of judgment and insight.
    2. Assessment of impulse control.
    3. Assessment of orientation, if authorized by the DDS
    4. Assessment of suicidal/homicidal ideation.

    NOTE:  ADULT MMSE TASKS TYPICALLY NOT APPROPRIATE FOR CHILDREN.

  10. Diagnosis, prognosis, and clinical assessment based on history and observations made during the mental examination. The assessment should include a description of any limitation(s) in the child’s ability to function effectively in an age-appropriate fashion which result from the condition(s)/impairment(s) evaluated.  Include a statement addressing the child’s limitations in acquiring/using information, attending and completing tasks, and interacting/relating to others.  This should not be phrased in the same way as for adults, e.g., simple versus complex instructions, accepting supervision, etc.

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Pediatric - Immune System Disorders

(Boldface type indicates requirements not found in the General Report)

General Guidelines
The report must be complete enough to help the DDS adjudicative team determine the medical severity and duration of the impairment(s), the type(s) of treatment and extra care required in the management of the impairment(s), and functional limitations related to the impairment(s).

  1. General
    1. Identify Claimant
      1. Include the claimant’s claim number, and
      2. Indicate that the claimant provided proof of identity by showing an original document proving U.S. citizenship, age and identity (social security card, U.S. passport, birth certificate, student or school ID, daycare center or school record), and
      3. Provide a physical description of the claimant, to help ensure that the person being examined is the claimant.
    2. Medical Records/History Documentation
      1. Cite the medical records and any other documents reviewed prior to, during the course of, or subsequent to the evaluation. Medical documents, including a copy of the relevant listings, provided by the DDS  should be listed.  A statement should be made if no medical documents were provided for review by the DDS.
      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 – Describe/discuss as appropriate:
    1. The child’s impairment(s) for which the SSI disability claim is being filed
    2. Onset and duration of the primary immunologic impairment(s)
    3. Constitutional symptoms (pain, fatigue, malaise, weight loss) and effects on mental, emotional, social, motor or special senses functioning
    4. Type, frequency and severity of systemic infections (sepsis, meningitis, endocarditis, osteomyelitis, etc.)
    5. Stem cell transplantation and any adverse effects
    6. Malignant neoplasm
    7. Difficult to control dermatologic conditions
    8. Current treatment plan including medicines and dosages, need for periodic adjustments in medication regimen, special therapy, equipment or devices
    9. Response to treatment and overall extent of control of the impairment(s)
    10. Names of source(s) and dates of medical care including specialist(s) or specialty clinic(s)

  3. Past Medical History – Describe/discuss as appropriate:
    1. Prenatal, delivery, and neonatal course
    2. Other significant events not covered in current medical history.  Provide names and dates of sources where care was given

  4. Review of Systems – Describe/discuss signs/symptoms and pertinent negative findings of the child relevant to the specific impairment(s) being evaluated and not otherwise described above in current medical history.

  5. Growth and Development – Describe/discuss as appropriate:
    1. Any delay in length/height or weight growth when impairment(s) would be expected to affect growth
    2. Developmental milestones if under age 6.  The results of a formalized developmental screening test can meet this requirement.
    3. Early infant or preschool intervention services
    4. For children 6 and older, usual daily activities
    5. Current grade, type of class, limitations of activities or need for special assistance or extra care

  6. Social History – Describe/discuss, as appropriate, based on the child’s age, pertinent findings about use of tobacco products, alcohol, non-prescription drugs, etc.

  7. Family History – Describe/discuss family composition, health of family members, including similar disease/disorder in other members of the family, the primary caretaker(s) and their role in providing for the child’s medical and daily activity needs.

  8. Physical Examination – The report should present aspects of the examination dealing with the child’s condition(s)/impairment(s) and describe both pertinent positive and negative findings.  The report should include:
    1. Length/Height and weight measurements and percentiles based on the most recent CDC growth standards
    2. Blood pressure, pulse, respiratory rate, temperature, if appropriate
    3. General appearance including any obvious vision or hearing problems, facial, skeletal or other abnormalities, as appropriate
    4. Description of the interaction with examiner and ability to understand directions and communicate clearly with content appropriate for age
    5. Exam to include:
      1. Joint pain, swelling, tenderness, contractures, deformities
      2. Muscle weakness, atrophy, pain
      3. Skin abnormalities
      4. Extra articular findings

  9. Interpretation of laboratory and other tests results when authorized and ordered by the DDS or otherwise available from medical records.  Examples include:
    • Serologic tests including immunoglobins, complement, T cells (as relevant to the disorder being evaluated)
    • Tissue biopsy, arthrocentesis
    • Electromyography
    • MRI, CT
    • Angiography
    • Urinalysis
    • Viral load, T cell levels for HIV claims

    Information on this report should include:

    1. The name and address of the medical source providing the formal interpretation of the laboratory tests when that source is other than the individual signing the CE report.
    2. An interpretation of all laboratory results that takes into account, and correlates with, the history and physical examination findings.

  10. Diagnosis, prognosis, and clinical assessment based on history, observations made during the physical examination, and results of relevant laboratory test(s). The  statement should include a description of any limitation(s) in abilities/activities which result from the condition(s)/impairment(s) evaluated.