BASIC (04-00)

A. Policy - Format and Detail

The format for reporting the results of the history, physical examination, laboratory findings, diagnosis and discussion of conclusions should follow the standard reporting principles for a complete and competent internal medicine examination.

The report must be complete enough to help the DDS adjudicative team determine the nature, severity, and duration of the impairment, and to help the team do a functional assessment of the child's impairment-related limitations.

B. Policy - Content

1. Source of History

The medical source should indicate from whom the history was obtained and should provide an estimate of the reliability of the history.

2. History of Present Illness

1. The chief complaint(s) alleged as the reason for the impairment should be discussed in detail, including:

   • A complete description of the problem(s);

   • How long the problem(s) has (have) been present;

   • If episodic, provide dates of episodes, precipitating factors, and the state of health and function of the child between episodes;

   • Factors that increase the problem or impairment(s);

   • Factors that may provide relief;

   • Any prescribed treatment and response to treatment, including compliance with treatment or lack thereof (report any side effects); and

   • A description of how the impairment(s) limits the child's ability to function.

2. Pertinent descriptive statements by the child or by the child's parent(s), other relative(s), caregiver, or other person who brought the child to the CE, such as a description of symptoms, should be recorded in the informant's own words.

3. The pertinent negative findings that would be considered in making a differential diagnosis of the current illness or in evaluating the severity of the impairment should be included.

4. The information must be in a narrative, rather than a “questionnaire” or “check-off” form.

3. Past History

Description of the past history should include:

1. The prenatal course, delivery course, and neonatal care.

2. Prior illnesses, injuries, operations, hospitalizations, and emergency room visits, including the dates of these events. When possible for hospitalizations, diagnosis (or reason), name of facility, dates of admission /discharge, and treatment given.

4. Current Medication

Current medication should be listed by name of drug and dose.

5. Review of Systems

Should describe and discuss other complaints and symptoms the claimant has experienced relative to the specific organ systems, with particular emphasis on those systems that may be affected by the claimant's allegation.

6. Growth and Development History

1. History of prior growth, when the alleged impairment would be expected to affect growth.

2. Developmental milestones, including speech and language (if the child is under age 5).

3. Preschool performance, if appropriate.

4. Activity in day-care, if appropriate

5. School performance, including physical activity and gym (if the child is age 5 or older).

6. Usual daily activities, including self-care, communicative abilities, social behavior with siblings, peers, and adults, details of any problems and /or need for special assistance, ability to concentrate and persist in activities as well as maintain an adequate pace.

7. Social History

The social history includes pertinent findings about the child's use of tobacco products, alcohol, nonprescription drugs, etc., should be presented, if appropriate, based on the child's age.

8. Family History

Information on the family history should be presented.

9. Physical Examination

The report should present aspects of the physical examination dealing with the claimant's major and minor complaints in particular detail, describing both pertinent negative and positive findings. The report should include:

1. The actual values and percentiles based on the National Center for Health Statistics data and standards for the child's:

   • Height without shoes (length without shoes if the child is under age 2);

   • Weight without shoes;

   • Head circumference if the child is under age 3, or if a neurological or mental impairment is involved; and

   • Tanner stage, as appropriate.

2. Blood pressure, pulse, respirations, if appropriate, based on the nature of the impairment(s).

3. General appearance of the child during exam:

   • Any obvious vision or hearing problems;

   • Facial dysmorphism;

   • Skeletal anomalies;

   • Other congenital anomalies; and

   • Any physical evidence indicating side effects of medication.

4. Description of child during the examination should be in a narrative, rather than a “questionnaire” or “check-off” form and should include:

   • Behavior and attention span;

   • How the child relates to and interacts with the examiner and the person who brought the child to the CE;

   • Affect (is it appropriate?);

   • Hearing;

   • Speech (for a child up to 3 years of age, are the quantity and quality of sounds produced, both spontaneously and on imitation, age-appropriate; for a child 3 years of age and older, can the child be understood?);

   • Receptive language (is the child's understanding of what is said to him/her age-appropriate in terms of vocabulary, content, etc., e.g., one-step directions, then two- and three-step directions?);

   • Expressive language (is the child's production of language age-appropriate, e.g., use of single words, then phrases, sentences?); and

   • Communicative ability (can the child — of any age — express different communicative intents (e.g., requests objects by age-appropriate nonverbal or verbal means), and engage in age-appropriate communicative behaviors (e.g., turn-taking, establishing and maintaining a topic)?)

   • Physical activity - gait, manipulation skills, sitting, crawling, walking, ability to roll over (for infants).

NOTE: Pelvic examinations should not be performed unless specifically authorized.

10. Laboratory Tests

1. The results of the laboratory test reports should provide:

   • Actual values for laboratory tests; and,

   • Normal ranges of values for the child's age in either the medical report or the laboratory report.

2. Reports of x-rays and other imaging studies of those body areas specifically requested should be provided.

3. Interpretation

   • The interpretation of laboratory tests (e.g., electrocardiographic tracings) or imaging studies must take into account and be correlated with the history and physical examination findings.

   • Identify the medical source providing the formal interpretation, when it is other than the physician (psychologist) signing the CE report.

   • If the interpretation is provided separately, the report sheet should state the interpreting medical source's name and address.

11. Other Testing

Developmental screening should be performed, if appropriate.

C. Policy - Specific Impairments

Listed in the following sections are specific requirements to be addressed for individual allegations in addition to the general guidelines in DI 22510.035B.

An impairment may significantly affect other body systems; in such cases, the additional body system must be evaluated as well.